Use Of Adjuvant Radiotherapy Research Articles

Prognostic factors for extra‐abdominal and abdominal wall desmoids: A 20‐year experience at a single institution

Previous reports even large studies discussing the prognosis of desmoids have included tumors from intra- and extra-abdominal sites as well as incomplete resection. The purpose of this study was to explore prognostic factors associated with the recurrence free survival (RFS) rate in surgically treated extra-abdominal and abdominal wall desmoids. A total of 198 consecutive desmoid patients were treated with surgery over a 20-year period at a single institution. Of these, 151 patients with extra-abdominal and abdominal wall tumors were retrospectively reviewed. One hundred thirteen patients were referred for the primary tumor and the other 38 for recurrent disease initially treated elsewhere. All patients underwent a macroscopically complete resection. The median follow-up interval was 102 months. Thirty-one patients (20.5%) had a local recurrence (LR). No patients died of the disease. The 5- and 10-year RFS was 79.7% and 78.5%, respectively. Admission status, gender, tumor size, margin status, location, and number, were predictors of LR in univariate analysis. Tumor size and margin status were independent prognostic factors in multivariate analysis. Positive margins were predictive of recurrence of primary disease, and also showed a trend for recurrent disease, which was not statistically significant. The selective use of adjuvant radiation did not show significant benefit over local control. Regardless of primary or recurrent disease, microscopically negative margins should always be the goal for extra-abdominal desmoids surgery, if no cosmetic defects or function demolition is encountered. Extra-abdominal desmoids deserve more attention and should be treated more aggressively, especially when leaving positive margins.

The benefits of adjuvant radiation therapy after therapeutic lymphadenectomy for clinically advanced, high‐risk, lymph node‐metastatic melanoma

The objective of this study was to evaluate the impact of adjuvant radiation therapy (RT) on regional recurrence and survival after therapeutic lymphadenectomy (TL) for clinically advanced, lymph node-metastatic melanoma. Six hundred fifteen patients who had clinically advanced, regional lymph node-metastatic disease underwent TL. All patients were appropriate potential candidates for adjuvant RT (enlarged or multiple positive lymph nodes, extracapsular extension) because of a high risk for regional recurrence regardless of whether or not they received RT. Patient-related, tumor-related, and treatment-related variables that were associated with recurrence, survival, and treatment-related morbidity with and without RT were analyzed. The median follow-up was 5 years. The actuarial 5-year regional lymph node basin control rate was 81%. On multivariate analysis, the number of positive lymph nodes, the number of lymph nodes removed, and the use of adjuvant RT were associated with improved regional control. Treatment-related morbidity, particularly lymphedema, was increased with the use of adjuvant RT and an inguinal site of lymph node metastases. At last follow-up, 268 patients were alive with actuarial 5-year distant metastasis-free survival (DMFS) and disease-specific survival (DSS) rates of 40% and 48%, respectively. On multivariate analysis, DMFS and DSS both were influenced by the number of positive lymph nodes and the number of lymph nodes removed. In addition, DSS was influenced by primary tumor thickness and the receipt of adjuvant RT. Adjuvant RT was associated with improved regional lymph node basin control compared with TL alone in patients with high-risk, clinically advanced, lymph node-metastatic melanoma. Although it is a regional therapy, adjuvant RT also may have an impact on DSS.

Infratentorial ependymomas: prognostic factors and outcome analysis in a multi-center retrospective series of 106 adult patients

This study was undertaken to analyze outcomes and to assess the prognostic impact of age, location, surgery, radiotherapy (RT), and histopathology in a series of adult infratentorial ependymomas. This was a retrospective study of a population of 106 adult patients with infratentorial ependymomas diagnosed between 1990 and 2004. A central pathological review of all cases was performed. Grading was according to the WHO and Marseille's neograding classifications. The series consisted of 58 males (54.7%) and 48 females (45.3%) in the age range of 18-82 years. Using the WHO classification, 88 patients (83.0%) had grade II and 18 patients (17.0%) grade III ependymomas. Using the Marseille's neograding system, 91 patients were low-grade and 15 high-grade. Gross total resection was achieved in 66 patients (62.3%). Thirty-seven patients (35.0%) received adjuvant RT. The 5- and 10-year overall survival rates for the entire cohort were 86.1% and 80.5%, respectively. On multivariate analysis, a preoperative Karnofski performance status score > 80, no recessus lateral extension and a low histological grade (Marseille's grading) were associated with a longer overall survival. The 5- and 10-year progression-free survival rates for the entire cohort were 70.8% and 57.7%, respectively. On multivariate analysis, no recessus lateral extension, gross total resection and a low histological grade (Marseille's grading) were associated with a longer progression-free survival. Adjuvant RT was significantly associated with a better overall and progression-free survival in incompletely resected WHO grade II ependymomas. This study highlights the key role of histology in the clinical outcome and the fact that gross total resection is a main prognostic factor and the treatment of choice for posterior fossa ependymomas. The use of adjuvant RT in patients with incompletely resected WHO grade II ependymomas appears beneficial, but its effect on high-grade tumors remains to be determined.

Non-epithelial ovarian cancer: ESMO Clinical Recommendations for diagnosis, treatment and follow-up

Non-epithelial ovarian cancer: ESMO Clinical Recommendations for diagnosis, treatment and follow-up

Adult gliosarcoma: epidemiology, natural history, and factors associated with outcome

The epidemiology and natural history of adult gliosarcomas (GSMs), as well as patient and treatment factors associated with outcome, are ill defined. Patients over 20 years of age with GSM diagnosed from 1988 to 2004 were identified in the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier survival analysis and Cox models were used to examine outcomes. Similar analyses were conducted for patients diagnosed with glioblastoma (GBM) over the same time period. GSM represented 2.2% of the 16,388 patients identified with either GSM or GBM. No significant differences between GSM and GBM were identified with respect to age, gender, race, tumor size, or use of adjuvant radiation therapy (RT). Patients with GSM were more likely to have temporal lobe involvement and undergo some form of tumor resection. The most important analyzed factors influencing GSM overall survival were age, extent of resection, and use of adjuvant RT. After adjusting for factors impacting overall survival, the prognosis for GSM appears slightly worse than for GBM (HR = 1.17, 95% CI, 1.05-1.31). GSM is a rare malignancy that presents very similarly to GBM with a slightly greater propensity for temporal lobe involvement. Optimal treatment remains to be defined. However, these retrospective findings suggest tumor excision, as opposed to biopsy only, and adjuvant RT may improve outcome. Despite therapy, prognosis remains dismal and outcomes may be inferior to those seen in GBM patients.

Local-regional recurrence with and without radiation after neoadjuvant chemotherapy and mastectomy for T3N0 breast cancer patients.

Abstract Abstract #74 Purpose: The goal of this study was to compare the local-regional recurrence (LRR) risk in patients with clinical T3N0 breast cancer who were treated with neoadjuvant chemotherapy (NeoChemo) and mastectomy (Mastx) according to the use of adjuvant radiation (RT).
 Methods: Clinicopathologic data from 164 patients with clinical T3N0 breast cancer who received NeoChemo and Mastx from 1985 to 2004 were retrospectively reviewed. In this cohort, 121 (74%) patients received adjuvant radiation (RT) while 43 (26%) patients did not. The median number of axillary lymph nodes (LN) dissected was 15. After NeoChemo, 54% of patients (n=89) had no pathologically involved lymph nodes at the time of surgery (ypLN-) while 46% (n=75) had at least 1 lymph node pathologically positive (ypLN+). Actuarial rates were calculated using Kaplan-Meier analysis and compared using log-rank test. Cox proportional hazards models were fit to determine the association of RT with the risk of LRR after adjustment for other patient and disease characteristics.
 Results: At a median follow-up of 77 months, 17 of the 164 patients had a LRR. For all patients, the 5-year local-regional control rates (5-yr LRC) were 90%. The 5-yr LRC for those who received RT (n=121) was 95% and for those who did not received RT (n=43) was 76% (p = 0.002), with a higher proportion of the patients who received RT having pathologically involved LN (+RT 53% vs –RT 23%, p=0.002).
 Among the entire cohort, the 5-yr LRC was 85% for patients with ypLN+ disease and 94% for patients with ypLN- disease (p=0.093). In patients with ypLN+, the 5-yr LRC with no RT (n=11) was 47% and with RT (n=64) was 92% (p<0.001). In patients with ypLN-, the 5-yr LRC with no RT (n=32) was 86% and with RT (n=57) was 98% (p=0.063). Patients who had tumors with high nuclear grade had worse 5-yr LRC (Grade low 100%, intermediate 97%, high 81%, p=0.023). The presence of lymphovascular invasion, close/positive margin, or estrogen receptor status did not statistically correlate with LRC. In a Cox regression model, patients with tumor exhibiting high nuclear grade (Hazard Ratio (HR) 5.0, 95% Confidence Interval (CI) 1.6-15.4), ypLN+ (HR 6.6, 95% CI 2.0-22.1) and no adjuvant RT (HR 7.6, 95% CI 2.4-24.0) had increased risk of LRR.
 Conclusions: Post mastectomy adjuvant RT appears to improve LRC in clinical T3N0 breast cancer patients treated with neoadjuvant chemotherapy and mastectomy. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 74.

Evidence-based adjuvant therapy for gliomas: Current concepts and newer developments

The incidence of gliomas is increasing worldwide, including India. Of the 18,820 new cases of primary central nervous system (CNS) tumors diagnosed annually in the United States, gliomas account for over 60% with 30-40% of them being glioblastoma multiforme (GBM), 10% being anaplastic astrocytoma (AA), and 10% being low grade gliomas (LGGs). This is in contrast to one study from West Bengal, India, in which only 7.9% of the brain tumors were GBMs, while 46.8% were astrocytomas. Of all adult primary CNS tumors, GBM is the most common and the most malignant with about 7,000 to 8,000 new cases annually in the United States. Given poor outcomes, a number of treatment approaches have been investigated. Common to these approaches is the use of adjuvant radiation therapy, even as surgery alone, with or without chemotherapy, may be the mainstay for some lower grade and low-risk gliomas. Today, treatment typically involves external beam radiation, with concurrent and adjuvant chemotherapy for more aggressive histologies. Although gliomas are relatively uncommon, active research is ongoing. Results of landmark trials along with some of the recently published trials are presented. These trials and management strategies as well as evolving concepts are found by reviewing over 200 articles in the National Library Medical (NLM) database, PubMed, more than 60 of which are refrenced. Specifically, the database is searched using the following keywords, with various combinations: glioma, low-grade, anaplastic, astrocytoma, oligodendroglioma, oligoastrocytoma, glioblastoma multiforme, chemotherapy, radiation, new concepts, phase III, MGMT, CDX-110 (Celldex), temozolomide, 1p/19q deletion, and bevacizumab.

The Role of Radiotherapy in the Treatment of Newly Diagnosed Supratentorial Low-grade Oligodendrogliomas: Comparative Analysis with Immediate Radiotherapy versus Surgery Alone

The purpose of this study was to evaluate the role of immediate postoperative radiotherapy (RT) in adult patients with a low-grade oligodendroglioma (LODG). A total of 74 patients, older than 15 years, were treated in our institution between April 1990 and March 2006 for newly diagnosed LODGs. After surgery, 43 patients were treated with immediate RT with a total dose of 54~55.8 Gy with 1.8 Gy fractions (RT group) and 31 patients were followed with no adjuvant RT (OP group). All patients were closely observed until tumor progression or death with frequent work-ups including neurological examinations and MRI. Primary endpoints were overall survival and progression-free survival. The median follow-up duration of survivors was 6.2 years in the RT group and 5.8 years in the OP group. Median progression-free survival was 13.2 years in the RT group and 4.6 years in the OP group; multivariate analysis confirmed improved outcome with the use of immediate RT (hazard ratio, 0.22; 95% confidence interval-CI, 0.09~0.55; p<0.001). Median overall survival was 14.9 years in the RT group and 9.8 years in the OP group; the use of adjuvant RT was also associated with a trend toward better overall survival after immediate RT based on multivariate analysis (hazard ratio, 0.3; 95% CI, 0.08~1.17; p=0.082). No severe RT related complications were observed. Immediate RT following surgery appears to be an effective treatment modality for supratentorial LODGs. However, the potential benefit of adjuvant RT for overall survival needs to be tested prospectively in the future.

Therapeutic lymphadenectomy alone versus adjuvant radiotherapy for regional nodal metastases from melanoma

9038 Background: To evaluate the impact of adjuvant radiation therapy on survival and recurrence patterns following therapeutic lymphadenectomy for regional nodal metastases from melanoma. Methods: Review of the melanoma databases at two institutions identified 615 patients who underwent therapeutic lymphadenectomy of which 509 patients received adjuvant regional radiotherapy. Patient, tumor, and treatment-related variables associated with survival, recurrence and treatment-related morbidity with and without the use of adjuvant radiotherapy were analyzed. Results: At a median follow-up of 5 years, 268 patients were alive with an actuarial disease-specific (DSS) and distant metastasis-free survival (DMFS) of 48% and 40% respectively. On multivariate analysis, DSS and DMFS were influenced by number of positive lymph nodes, number of lymph nodes removed and in addition, DSS was also influenced by the use of adjuvant radiation therapy and thickness of the primary melanoma. Five-year DSS was 51% with the use of adjuvant radiation therapy and 30% without its use(p <0.0001). The actuarial 5-year regional in-basin control rate for all patients was 81%. On multivariate analysis, the 5-year regional control rates were superior with <4 positive lymph nodes (85% vs. 74%), ≥15 lymph nodes removed (84% vs. 76%) and the use of adjuvant radiation therapy (87% vs. 52%). Treatment-related morbidity particularly the 5-year risk of lymphedema was significantly increased with the use of adjuvant radiotherapy (22% vs. 9%) and inguinal site of nodal metastases (52% vs. 26% for axilla). Conclusions: The use of adjuvant regional radiotherapy following an adequate lymphadenectomy improves disease-specific survival and regional control rates with an increased risk of chronic lymphedema. No significant financial relationships to disclose.

Hitting a moving target: evolution of a treatment paradigm for atypical meningiomas amid changing diagnostic criteria

The World Health Organization (WHO) reclassified atypical meningiomas in 2000, creating a more clear and broadly accepted definition. In this paper, the authors evaluated the pathological and clinical transition period for atypical meningiomas according to the implementation of the new WHO grading system at their institution. A total of 471 meningiomas occurring in 440 patients between 1994 and 2006 were retrospectively reviewed to determine changes in diagnostic rates, postoperative treatment trends, and early outcomes. Between 1994 and 2000, the incidence of the atypical meningiomas ranged from 0 to 3/year, or 4.4% of the meningiomas detected during the entire period. After 2002, the annual percentage of atypical meningiomas rose over a 2-year period, leveling off at between 32.7 and 35.5% between 2004 and 2006. The authors also found a recent trend toward increased use of adjuvant radiation therapy for incompletely resected atypical meningiomas. Prior to 2003, 18.7% were treated with this therapy; after 2003, 34.4% of lesions received this treatment. Incompletely resected tumors were treated with some form of radiation 76% of the time. In cases of complete resection, most patients were not given adjuvant therapy but were expectantly managed by close monitoring using serial imaging and by receiving immediate treatment for tumor recurrence. The overall recurrence rate for expectantly managed tumors was 9% over 28.2 months, and 75% of recurrences responded to delayed radiation therapy. The authors documented a significant change in the proportion of meningiomas designated as atypical during a transition period from 2002 to 2004, and propose a conservative strategy for the use of radiation therapy in atypical meningiomas.

Radiotherapy to Improve Local Control Regardless of Surgical Margin and Malignancy Grade in Extremity and Trunk Wall Soft Tissue Sarcoma: A Scandinavian Sarcoma Group Study

Adjuvant radiotherapy has during the past decades become increasingly used in the treatment of localized soft tissue sarcoma. We evaluated the effect of radiotherapy (RT) on local recurrence rates (LRRs) in Scandinavia between 1986 and 2005. A total of 1,093 adult patients with extremity or trunk wall soft tissue sarcoma treated at four Scandinavian sarcoma centers were stratified according to the treatment period (1986-1991, 1992-1997, and 1998-2005). The use of adjuvant RT, quality of the surgical margin, interval between surgery and RT, and LRR were analyzed. The median follow-up was 5 years. The use of RT (77% treated postoperatively) increased from 28% to 53%, and the 5-year LRR decreased from 27% to 15%. The rate of wide surgical margins did not increase. The risk factors for local recurrence were histologic high-grade malignancy (hazard ratio [HR], 5), an intralesional (HR, 6) or marginal (HR, 3) surgical margin, and no RT (HR, 3). The effect of RT on the LRR was also significant after a wide margin resection and in low-grade malignant tumors. The LRR was the same after preoperative and postoperative RT. The median interval from surgery to the start of RT was 7 weeks, and 98% started RT within 4 months. The LRR was the same in patients who started treatment before and after 7 weeks. The results of our study have shown that adjuvant RT effectively prevents local recurrence in soft tissue sarcoma, irrespective of the tumor depth, malignancy grade, and surgical margin status. The effect was most pronounced in deep-seated, high-grade tumors, even when removed with a wide surgical margin.

Patterns of care analysis among women with ductal carcinoma in situ in North Carolina

BackgroundDuctal carcinoma in situ (DCIS) of the breast comprises approximately 25% of new breast cancer cases. The aim of this study was to delineate patterns of care for women with DCIS as related to age, tumor characteristics, and race/ethnicity. Further study goals included the identification of predictors of breast-conserving surgery (BCS), adjuvant radiation, and/or hormonal therapy, as well as breast reconstruction after mastectomy. MethodsThe North Carolina Cancer Registry was queried for primary DCIS treated in 1998 and 1999 (n = 1,893). Logistic regression analysis was performed to define the determinants of patterns of care. ResultsThirty-five percent of the women in this study sample underwent mastectomy. Positive predictors of mastectomy included young age (age <50 y vs 70+; odds ratio [OR], 1.55; 95% confidence interval [CI], 1.13–2.11) and larger tumor size (>2 mm vs 0–1 mm; OR, 2.43; 95% CI, 1.63–3.60). Approximately 48% of women who underwent BCS received adjuvant radiation therapy. Factors associated with receiving radiation therapy after BCS include younger age (age <50 vs 70+; OR, 2.12; 95% CI, 1.49–3.03). Approximately 19% of women who underwent BCS received adjuvant hormonal therapy. Positive predictors of receiving adjuvant hormonal therapy after BCS included age of 50 to 60 years versus 70+ (OR, 2.16; 95% CI, 1.36–3.44) and the receipt of radiation therapy (OR, 3.60; 95% CI, 2.55–5.06). Approximately 28% of women who underwent mastectomy received breast reconstruction surgery. Positive predictors of breast reconstruction after mastectomy included age younger than 50 years versus 70+ years (OR, 47.36; 95% CI, 19.45–115.32). African American race was associated negatively with receipt of breast reconstruction after mastectomy (OR, .46; 95% CI, .26–.84). ConclusionsTreatment strategies for primary surgical therapy for DCIS vary significantly by age. Inconsistencies exist surrounding the use of adjuvant radiation therapy after BCS in women with DCIS. Variations in approaches to reconstructive surgery after mastectomy may be related to age, ethnicity, and/or economic constraints.

The use of adjuvant radiation therapy in early endometrial cancer by members of the Society of Gynecologic Oncologists in 2005

The use of adjuvant radiation therapy in early endometrial cancer by members of the Society of Gynecologic Oncologists in 2005

Adjuvant Radiotherapy and Survival for Patients With Node-Positive Head and Neck Cancer: An Analysis by Primary Site and Nodal Stage

Adjuvant radiotherapy (RT) is frequently recommended for node-positive head and neck squamous cell carcinoma (HNSCC) treated with primary surgery. The impact of RT on survival for various subgroups of node-positive HNSCC has not been clearly demonstrated. Within the Surveillance, Epidemiology, and End Results (SEER) Database, we identified 5297 patients with node-positive (N1 to N3) HNSCC treated with definitive surgery with or without adjuvant RT between 1988 and 2001. The median follow-up was 4.4 years. Adjuvant RT significantly improved 5-year overall survival (46.3%: 95% confidence interval [CI], 44.7-48.0% for surgery + RT, vs. 35.2%: 95% CI, 32.0-38.5% for surgery alone, p < 0.001) and cancer-specific survival (54.8%: 95% CI, 53.2-56.4% for surgery + RT, vs. 46.2% for surgery alone 95% CI, 42.4-50.0%, p < 0.05). Use of adjuvant RT remained a significant predictor of survival on multivariable analysis (hazard ratio [HR], 0.75; 95% CI, 0.68-0.83; p < 0.001). Subset analyses demonstrated that adjuvant RT was associated with significantly improved survival for N1 (HR, 0.78; 95% CI; 0.67-0.90; p = 0.001), N2a (HR, 0.82; 95% CI, 0.67-0.99, p = 0.048) and N2b to N3 nodal disease (HR, 0.62; 95% CI, 0.51-0.75; p < 0.001). Adjuvant RT increased overall survival for node-positive patients with oropharynx (HR, 0.72; 95% CI, 0.57-0.90; p = 0.004), hypopharynx (HR, 0.66; 95% CI, 0.49 to 0.88; p = 0.004), larynx (HR, 0.66; 95% CI, 0.52-0.84; p = 0.001), and oral cavity (HR, 0.84; 95% CI, 0.73-0.98; p = 0.025) primary tumors. In a large population-based analysis, adjuvant RT significantly improves overall survival for patients with node-positive HNSCC. All nodal stages, including N1, appear to benefit from the addition of RT to definitive surgery.

The role of Adjuvant Radiation therapy in Endometrial carcinoma

Endometrial cancer is a third common gynecologic malignancy in Korea, affecting approximately 714 women per year. Despite the publication of several prospective randomized trials, there continues to be controversy regarding the use of adjuvant radiation therapy in endometrial cancer management. It is clear that most women with early stage, low-risk disease will do well without adjuvant therapy. Intermediate-risk patients are at risk for local regional relapse, and radiotherapy has been shown to effectively reduce this risk without significantly impacting overall survival. The absence of a clear impact on survival has resulted in a lack of consensus regarding the use of radiotherapy in intermediate-risk patients. At the same time, the patterns of failure in intermediate-risk patients have resulted in differing recommendations regarding appropriate radiotherapy targets. High-risk patients are also at risk for local failure, and targeted radiotherapy may be appropriate. In this article, we discuss the controversies surrounding the role of adjuvant radiotherapy in endometrial cancer using an evidence-based approach.

Therapeutic management of intracystic papillary carcinoma of the breast: the roles of radiation and endocrine therapy

Background The role of radiation and endocrine therapy in the treatment of intracystic papillary carcinoma (IPC) remains unclear. The aim of the current study was to review the management of IPC in order to determine factors associated with use of adjuvant therapies. Methods A retrospective review of our surgical and pathology databases from 1995–2006 identified 45 women with IPC. These patients were further divided into those with pure IPC (n = 21), IPC with associated ductal carcinoma in situ (DCIS) (n = 18), and IPC with associated microinvasion with or without DCIS (n = 6). Patient characteristics were compared between groups using the chi-square test. Results Patients with IPC and microinvasion were more likely to undergo an axillary staging procedure (6/6, 100%) compared to patients with pure IPC (6/21, 29%) or IPC with DCIS (5/18, 28%) ( P < .001). Patients with pure IPC were less likely to have radiation therapy than patients with IPC and DCIS or microinvasion ( P < .001). However, within the subset of patients with pure IPC, women less than 50 years of age were more likely to have radiation therapy than those older than 50 years ( P < .001). Patients with IPC and DCIS or microinvasion had significantly increased use of endocrine therapy versus patients with pure IPC ( P < .01). Conclusions In our patient population, those patients with IPC and associated DCIS or microinvasion are treated with adjuvant radiation and endocrine therapy on the basis of this associated pathology. The use of adjuvant radiation and/or endocrine therapy should be considered in patients with pure IPC who are of young age (<50 years).

Multimodality therapy for pancreatic cancer in the U.S.

Despite decreased perioperative morbidity and mortality and clinical trials suggesting improved outcomes with adjuvant therapy, national practice patterns in the management of pancreatic cancer remain poorly defined. The purpose of the current study was to evaluate multimodality therapy utilization and outcomes relative to hospital type and volume. Using the National Cancer Data Base, stage-specific treatment patterns were analyzed for 301,033 patients with pancreatic adenocarcinoma. Logistic regression was used to evaluate treatment utilization. Cox proportional hazards modeling was utilized to evaluate the effect of multimodality therapy on survival. Stage at presentation did not differ from 1985-1994 to 1995-2003; however, the percentage of patients receiving cancer-directed treatment increased from 45.1% to 51.8% (P < .001). Pancreatectomy for localized disease (AJCC 6th edition stages I and II) increased from 36.9% to 49.3% (P < .001). After resection, the use of adjuvant chemotherapy alone increased from 4.1% to 5.7% (P < .001), but the use of adjuvant radiation alone decreased from 7.0% to 4.6% (P < .001). Adjuvant chemoradiation use increased from 26.8% to 38.7% (P < .001). The use of surgery alone decreased from 62.1% (5213 of 8400 cases) to 49.9% (10,807 of 21,679 cases) (P < .001). Patients with localized pancreatic cancer were more likely to receive pancreatectomy and adjuvant chemoradiation at academic and high-volume centers (P < .001). Survival for localized disease was better after surgery with adjuvant therapy (hazards ratio [HR], 0.44; 95% confidence interval [95% CI], 0.42-0.47) and surgical resection alone (HR, 0.54; 95% CI, 0.52-0.57) compared with no treatment. To the authors' knowledge, the current study is the largest study regarding pancreatic cancer performed to date, and the first to investigate national practice patterns for multimodality therapy utilization. Multimodality therapy utilization has increased over time and appears to have a beneficial impact on survival.

Adjuvant Radiotherapy for Thymic Epithelial Tumor

To determine whether the use of adjuvant radiation in the treatment of invasive thymic tumors affects survival and to identify prognostic factors. The files of 47 patients with thymic tumors treated by adjuvant radiation in our institute from 1984 to 2003 were reviewed for data on prognosis and survival. All patients underwent thoracotomy followed by either total macroscopic resection (n = 42) or biopsy (n = 5). The radiation dose ranged from 26 to 60 Gy. Median duration of follow-up was 10.6 years. Overall 5-year survival was 73% (60%-88%): 77% for thymoma (n = 35/45) versus 33% for thymic carcinoma (n = 2/6) (P = 0.14). Better survival was associated with lower disease stage (II vs. III/IVA, P = 0.01), resection (P = 0.0004), myasthenia gravis at presentation (P = 0.04), and higher radiation dose (<or=45 vs. >45 Gy, P = 0.02); sex, smoking, tumor size, pathology, and margin status had no effect. Locoregional relapse occurred in 11 patients and distant metastasis in 4. The 5-year disease-free survival was 67% (52%-86%), with a median time to recurrence of 8.3 years. The better overall survival and disease-free survival associated with higher doses of radiation were also true for stage II patients. On multivariate analyses after adjusting for age, higher disease stage and lower radiation dose were found to adversely affect overall survival and disease-free survival. Thymic carcinoma had an impact only on disease-free survival. Postoperative radiation therapy to doses above 45 Gy may improve the disease-free and overall survival of patients with invasive thymoma, especially stage II. Thymic carcinoma has a worse prognosis.

Wisconsin Comorbidity Assessment Scale (WCAS): A novel, comprehensive, performance-based assessment scale of geriatric syndromes and medical comorbidities in older cancer patients

19619 Background: Elderly patients with cancer have potential for multiple geriatric syndromes that influence treatment and outcomes. No single clinical assessment tool has targeted all the major geriatric syndromes and their interaction on cancer management and outcomes. We developed WCAS to evaluate cognitive and physical function, risk of falls and gait disorders, polypharmacy, and medical comorbidities. Methods: Eighteen newly diagnosed patients with breast cancer (age 55–82), were enrolled prior to cancer treatment. Cognitive function was evaluated with a comprehensive battery of neuropsychological tests targeting the domains of memory, executive function, attention, language, and praxis. Physical function skills were assessed with novel performance-based tasks (e.g., bed-making) and computerized assessments of balance, gait and risk of falls. Cancer treatment included surgery in all patients with variable use of adjuvant radiation and medical therapy. WCAS was administered at baseline and at month 6. Results: Ten subjects have completed both baseline and month 6 visits. Surgical treatment occurred at a mean of ten days after baseline assessment (SD 6.7). The mean (SD) of the age, years of education and baseline Mini Mental Status Exam (MMSE) was 66 years (7.3), 15.2 years (3.7) and 29.3 (1.1). From baseline to month six assessment performance on the WAIS Digit Symbol test, a measure of working memory and processing speed, declined (mean change −11.7, p&lt;0.01). Likewise, the performance on the WAIS letter number sequence test (mean change −1.3, p=0.09) and the MMSE (mean change −1.1, p=0.12) declined. Interestingly, four subjects with pre-existing hypothyroidism on replacement treatment showed a greater decline (p&lt;0.01) in memory than those without this common condition. Conclusions: Findings indicate that breast cancer diagnosis and therapy can be associated with significant decline in aspects of cognition in older adults with cancer. These changes can last at least 6 months and are more pronounced in those with hypothyroidism. Larger, longer term prospective studies utilizing WCAS are necessary to confirm our preliminary findings. No significant financial relationships to disclose.

Impact of surgical treatment on survival in patients with primary rectal melanoma

19001 Background: Reports of melanoma of the lower GI tract, especially in the rectal area, were often grouped with diseases from the anal canal region. Outcome and pattern of care regarding primary melanoma of the rectum only were not well described in the literature. This review examined the utilization of surgery, radiotherapy (RT), and the potential impact on survival outcome in this subgroup of patients. Methods: The Surveillance, Epidemiology, and End Results (SEER) database (1973 to 2003) was searched. Only patients with primary melanoma of the rectum (excluding anal lesions) with recordable pathology reports were included. 79 patients were identified. 61 of them had melanoma of the rectum as the sole primary disease, and these patients were the focus of this study. Kaplan Meier estimation and Cox-Mantel test were used to calculate and compare survival rates. Results: Among the 61 patients, 20 patients did not have further surgery after biopsy. Another 20 patients had surgery, but the types of procedure were unknown. Of the remaining 21 patients eligible for analysis, eight patients had abdominoperineal resection (APR), and one of them received postoperative RT. Thirteen patients had partial proctectomy (PP), and none had RT. In univariate analysis, the 5-year overall survival rates for APR and PP groups were 12.5% and 7.7% respectively (p=0.63). There were one survivor in each group at the last follow up period with crude survival time of 15 years and 13.5 years respectively. More patients in APR group had locoregional disease (extramural and nodal) than in PP group (63% versus 0% respectively) at diagnosis. Comparing the time intervals by decade between 1973 to 1982, 1983 to 1992, and 1993 to 2003 in all 61 patients, use of postoperative RT was relatively limited at 1 in 14 cases, 1 in 19 cases, 2 in 28 cases respectively. RT was used mostly in patients who were not candidate for surgery and in patients with metastatic disease at diagnosis presumably for palliation. Conclusions: Primary melanoma of the rectum is a rare disease. Data for analysis were limited. There was no significant difference in overall survival between patients who had APR versus PP although APR group had higher tumor burden at diagnosis than PP group. Use of adjuvant RT is rare, and its role has yet to be further defined. No significant financial relationships to disclose.