T3N0 Disease Research Articles

Adjuvant irradiation after radical prostatectomy for adenocarcinoma of prostate: Analysis of freedom from psa failure

A total of 84 consecutive men with extracapsular disease after radical prostatectomy who received postoperative irradiation and no adjuvant endocrine therapy were analyzed. Failure was defined as the development of clinical disease recurrence either locally or at a distant site, the development of detectable prostate-specific antigen (PSA) when postoperatively it had been undetectable, or any rise in PSA when postoperatively it still had been detectable. Sixteen of the 84 men had nodal disease. Overall, five-year actuarial freedom from relapse was 60 percent. For node-negative men, it was 64 percent and for node-positive men 43 percent. For the 68 men with pathologic Stage T3N0 disease, five-year freedom from relapse was 73 percent when seminal vesicles were negative and 43 percent when involved. Tumor grade also predicted the likelihood of recurrence. In a multivariate analysis the time interval from surgery to radiation and the level of postoperative PSA (detectable versus undetectable) did not influence the likelihood of relapse nor the median time to relapse. Fourteen separate patients treated with radiation alone for palpable tumor recurrence were also analyzed. Fewer than 40 percent were disease-free only two years after irradiation. We conclude that when treatment failure is defined in biochemical as well as clinical terms postoperative irradiation reduces the rate of relapse at five years relative to recently reported series in which adjuvant irradiation was not given. The additional morbidity is low. Whether or not this will translate into an overall cause-specific survival gain is currently unclear.

Radiation therapy in management of carcinoma of the vulva with emphasis on conservation therapy

This report consists of a retrospective analysis of 50 patients with primary invasive and 17 with recurrent histologically confirmed vulvar carcinoma treated with radiation therapy for locoregional disease. Of the patients with primary tumors, 13 were treated with wide local excision plus radiation therapy; 13 had radical vulvectomy followed by irradiation to the operative fields and inguinal-femoral/pelvic lymph nodes; 8 received similar postoperative radiation therapy after partial or simple vulvectomy; 16 patients had radiation therapy alone after biopsy; and 17 had recurrent tumors treated with radiation therapy alone. In patients treated with biopsy/local excision, local tumor control was 92-100% in T1-3N0 disease, 40% in similar stages with N1-3, and 27% in recurrent tumors. Among patients treated with partial/radical vulvectomy and radiation therapy, primary tumor control was 90% in those with T1-3 tumors and any nodal stage, 33% in those with any T stage and N3 lymph nodes, and 66% in patients with recurrent tumors. The actuarial 5-year disease-free survival rates were 87% for patients with T1N0 disease, 62% for those with T2-3N0 disease, 30% for those with T1-3N1 disease, and 11% for patients with recurrent tumors; there were no long-term survivors with T4 or N2-3 disease. Four of 17 patients treated for postvulvectomy recurrent disease remain disease-free after local tumor excision and radiation therapy. In patients with T1-2 tumors treated with biopsy/wide tumor excision and radiation therapy with doses less than 50 Gy, the local tumor control was 75% (three of four patients), in contrast to 100% (13 of 13 patients) with 50.01-65 Gy. With T3-4 tumors treated with local excision and radiation therapy, tumor control occurred in none of three patients with doses less than 50 Gy and 66% (six of nine) with 50.01-65 Gy. In patients with T1-2 tumors treated with partial/radical vulvectomy and radiation therapy, local tumor control was 75% (six of eight), regardless of dose level; in T3-4 tumors, it was 67% (four of six patients) with 50-60 Gy and 86% (six of seven) with 65-70 Gy. Differences were not statistically significant. There was no significant dose response for tumor control in the inguinal-femoral lymph nodes, with doses of 50 Gy being adequate for elective treatment of nonpalpable lymph nodes and 60-70 Gy controlling tumor growth in 75-80% of patients with N2-3 nodes when administered postoperatively, after partial or radical lymph node dissection. Significant treatment morbidity included one rectovaginal fistula, one case of proctitis, one rectal stricture, four bone/skin necroses, four vaginal necroses, and one groin abscess. Wide local tumor excision and radiation therapy or irradiation alone in T1-2 tumors is an alternative treatment to radical vulvectomy in controlling vulvar carcinoma, with significantly less morbidity. In comparison with reported rates for surgery alone, radiation therapy after radical vulvectomy for locally advanced tumors improves tumor control at the primary site and regional lymphatics. Indications and techniques of radiation therapy are discussed.

Factors Influencing Survival and Prognosis in Early Breast Carcinoma (T1N0M0–T1N1M0): Assessment of 644 Patients with Median Follow-up of 18 Years

That there is probably a significant proportion of "cured" patients, particularly in the T1N0 group, is an important observation when one considers the proper role of adjuvant therapy, especially for patients with stage I disease. Analysis of this series indicates that patients with T1N0 disease can be subdivided into different prognostic groups. Factors associated with an especially favorable prognosis in T1N0 cases are a primary tumor size of 1 cm or less; special tumor type such as tubular, medullary, papillary, or colloid carcinoma; and low-grade tumor. Relatively unfavorable tumor characteristics are size greater than 1.0 cm (especially the group 1.7 to 2.0 cm), the presence of lymphatic tumor emboli in the breast, blood vessel invasion, high-grade tumor or poor differentiation, and intense peritumoral lymphoplasmacytic reaction. The T1N0 patients whose tumors manifest the latter features may have longer disease-free survival as a result of adjuvant therapy. On the other hand, women in the T1N0 group with an especially favorable prognosis usually can be spared adjuvant therapy.

Stage I and II breast carcinoma: treatment with limited surgery and radiation therapy versus mastectomy.

Between 1980 and 1986, 2,140 patients with surgical stage I or II breast carcinoma were treated including 1,179 patients with T1-2N0 disease and 961 patients with T1-2N1 disease. Among the 1,179 patients without node involvement, 215 underwent limited surgery (complete excision and axillary node dissection) and radiation therapy; 964 patients underwent modified radical mastectomy only. Of the 961 patients with node involvement, 106 were treated by means of limited surgery and radiation therapy; of these, 48 also received chemotherapy. The remaining 855 patients underwent mastectomy; of these, 381 also received chemotherapy and/or hormone therapy. The 5-year survival rates for patients with no node involvement were 96% for the group treated by means of limited surgery and radiation therapy and 88% for the group treated by means of mastectomy (P greater than .05). The 5-year survival rates for patients with node involvement were 96% for the group treated by means of limited surgery and radiation therapy with or without chemotherapy and 77% for the group treated by means of mastectomy with or without chemotherapy (P less than .01). This study demonstrates no disadvantage from treatment by means of limited surgery and radiation therapy and suggests that adjuvant radiation therapy may be important in increasing survival among patients with T1-2 breast carcinoma and positive axillary nodes.

Results of Surgical Treatment of Patients with T3 Non—Small Cell Lung Cancer

Sixty-one patients with T3 non-small cell lung cancer were surgically treated in our department from February, 1974, through April, 1986. The overall 5-year survival, excluding patients with pleurisy, was 23%, and the 5-year survival for patients undergoing complete resection and incomplete resection was 42% and 10%, respectively ( p < 0.01). Survival in patients with T3 N0 and T3 N1 or N2 disease was 33% and 0 at 5 years, respectively. The prognosis for patients with pleurisy was poor, and all died within 3 years. Therefore, complete lung resection should be done in patients with T3 N0 non-small cell lung cancer if complete resection is expected. Long-term survival is less likely for patients with lymph node metastases if complete resection cannot be performed.

Importance of biologic status to the postoperative prognosis of patients with stage III nonsmall cell lung cancer.

The prognosis of patients with stage III nonsmall cell lung cancer was studied, with special attention to their biologic status prior to lung resection. The biologic status was estimated from the neutrophil/lymphocyte ratio in the peripheral blood, serum albumin level, and erythrocyte sedimentation rate. Among 46 patients who underwent potentially curative operations, 31 cases of biologic status A or B (more than two parameters normal) revealed 37.6% of a 5-year survival rate, whereas there was no 5-year survivor in 15 cases of biologic status C or D (more than two parameters abnormal). Of the 5-year survival rate in T3N0 disease of biologic status A or B, the 60% surviving (of 10 cases) was in marked contrast to the same stage disease of biologic status C or D where only 1 patient (of 10 cases) was still surviving at more than 30 months. In 30 patients with T3N0, T3N1, and T2N2 diseases of biologic status A or B, where long-term survivors were derived, the 5-year survival rate in 30 patients of biologic status A or B was 36.6% in contrast to no long-term survivor in the same stage diseases of biologic status C or D (n = 25). We conclude that surgical results in stage III nonsmall cell lung cancer will be beneficial in patients of biologic status A or B, but nonbeneficial in patients with the same stage of biologic status C or D.

The Biological Operability of Stage III Non-Small Cell Lung Cancer

Stage III non-small cell lung cancer represents a broad spectrum of anatomical and histological subsets of patients with differing biological characteristics and prognostic expectations. Our experience with 161 consecutive patients undergoing complete resection for Stage III non-small cell lung cancer at the M. D. Anderson Hospital and Tumor Institute from 1965 through 1980 includes 69 patients with T3 N0 or N1 disease and 92 patients with an N2 classification. The cumulative 5-year survival overall was 30%: 35.6% for the T3 N0 or N1 group and 26% for the N2 patients. Seventy-three patients had squamous cell carcinoma and 76, adenocarcinoma. Small numbers of patients had other miscellaneous classifications (N = 12). In the T3 N0 or N1 subset, 43% of the patients with squamous cell carcinoma (N = 37) and 23% of those with adenocarcinoma (N = 25) survived 5 years. In the N2 subset, 39% of the patients with squamous cell carcinoma (N = 36) and 14% of the group with adenocarcinoma (N = 52) achieved long-term survival. Failure of treatment was clinically documented in 61 patients. The first observed recurrence or metastasis was at a distant site in the majority of these patients. Operative intervention for patients with Stage III M0 non-small cell lung cancer is effective and reflects the impact and limitations of resection on disease progression. Adjuvant irradiation was not shown to improve the outcome over the results of operation alone. Effective systemic therapy will be required to produce substantial changes in end results.

Adverse prognostic effect of N2 disease in treated small cell carcinoma of the lung

We reviewed survival of patients with clinically localized small cell carcinoma of the lung treated by surgical resection, combination chemotherapy, and prophylactic cranial irradiation. Long-term survival was defined as continuing complete remission 30 months after the start of treatment. Initial TNM staging determined the course of treatment. Ten patients with disease in Stages I and II were treated over 30 months ago by initial resection followed by the full course of chemotherapy. Only one has had a relapse, whereas 80% remained disease-free at 30 months. Five of these patients have passed 5 years. Four patients with T3 N1 disease were treated by two cycles of chemotherapy, surgical resection, and cranial irradiation plus resumption of chemotherapy thereafter; two remained in remission at 30 months. Sixteen patients initially with N2 disease were treated according to the same schedule; 10 of the 16 underwent successful resection. All 16 patients have had a relapse, but the relapse occurred very late in three--at 27, 30, and 37 months. The reasons for the apparently poor prognosis of N2 disease are not clear. Considerations of tumor response kinetics and somatic mutation suggest that these biologic factors are fundamentally responsible. Other studies may find disease control achieved in a very few patients with N2 disease.

Prognostic significance of N1 disease in carcinoma of the lung

From 1973 to 1981, 75 patients with T1 N1 M0 and T2 N1 M0 disease had a complete, potentially curative resection with mediastinal lymph node dissection. Thirty-eight had adenocarcinomas, 36 epidermoid cancer and one large cell carcinoma. Surgical treatment consisted of lobectomy in 54, sleeve lobectomy in three, and pneumonectomy in 18. Two patients died postoperatively. Of 17 patients with T1 N1 disease, 14 had no further treatment and three received postoperative radiation and/or chemotherapy; the 5 year cumulative survival rate of these patients was 56%. There were 58 patients with T2 N1 disease. Forty-five had no further treatment and 13 received postoperative radiation and/or chemotherapy; the 5 year cumulative survival rate of these patients was 48%. The overall incidence of local and regional recurrence was low, and the brain was the most frequent site of recurrence. Factors influencing recurrence were histology and proximity of the tumor to hilum. The specific nodes involved, the number of nodes affected, and the extent of involvement within the nodes had no observed effect on survival. There was no observed improvement in survival with the use of adjuvants. However, survival was significantly poorer in patients with visceral pleural involvement.

Bassini's Operation for Inguinal Hernia

The purpose of this study was to prospectively evaluate the role of ¹⁸F-FDG PET/CT in patients with stage IIA, IIB, or IIIA breast cancer. <b>Methods:</b> During 56 mo, 131 consecutive patients with large (&gt;2 cm) breast cancer and clinical stage IIA, IIB, or IIIA (based on clinical examination, mammography, breast MRI, and ultrasonography) underwent ¹⁸F-FDG PET/CT. The nuclear physician was unaware of the results of any other procedure (bone scan, chest radiography, liver ultrasound, or thoracoabdominal CT scan). <b>Results:</b> Of the 131 examined patients, 36 had clinical stage IIA (34 T2N0 and 2 T1N1), 48 stage IIB (20 T3N0 and 28 T2N1), and 47 stage IIIA (29 T3N1, 9 T2N2, and 9 T3N2). ¹⁸F-FDG PET/CT modified staging for 5.6% of stage IIA patients, for 14.6% of stage IIB patients, and for 27.6% of stage IIIA patients. However, within stage IIIA, the yield was specifically high among the 18 patients with N2 disease (56% stage modification). When considering stage IIB and primary operable IIIA (T3N1) together, the yield of ¹⁸F-FDG PET/CT was 13% (10/77); extraaxillary regional lymph nodes were detected in 5 and distant metastases in 7 patients. In this series, ¹⁸F-FDG PET/CT outperformed bone scanning, with only 1 misclassification versus 8 for bone scanning (<i>P</i> = 0.036). <b>Conclusion:</b>¹⁸F-FDG PET/CT provided useful information in 13% of patients with clinical T3N0, T2N1, or T3N1 disease. The yield was more modest in patients with stage IIA. The high yield in the case of N2 disease demonstrates that stage IIIA comprises 2 quite distinct groups of patients.