Use Of Postoperative Radiotherapy Research Articles

Postmastectomy radiotherapy in the management of operable breast cancer.

There is a long and detailed history of radiation therapy as an adjuvant to surgery in operable breast cancer. The results of a large number of randomized clinical trials will be reviewed. They can be summarized by saying that although the trials show a reduction in local-regional failure with the use of postoperative radiotherapy, a survival advantage has not been clearly identified. Many of the older trials used techniques and radiation doses inadequate by current standards, which may have affected the results. Recent trials that used therapeutic doses of radiation, however, did demonstrate a survival advantage among patients who received postoperative radiotherapy. These trials generally have included chemotherapy and required careful integration of radiotherapy and systemic therapy. Although all trials have not demonstrated a survival benefit by the addition of radiotherapy, the ability to maintain local-regional control after mastectomy is an important goal. Administration of prophylactic chest wall and nodal radiotherapy to patients at high risk for local-regional recurrence significantly reduces the chance of a local treatment failure. Because a chest wall recurrence is a distressing event that dramatically affects quality of life, improved local-regional control with postoperative radiotherapy is a highly significant end point.

Surgical management of adenoid cystic carcinoma in the parotid gland.

Although adenoid cystic carcinoma may be found in multiple sites in the head and neck as well as other glandular sites throughout the body, nowhere is management of the disease more controversial than in the parotid gland. Here the facial nerve is at risk from both the disease and the treatment. Seventy-five cases of adenoid cystic carcinoma of the parotid were analyzed. Patients were placed in four groups, depending on the type of parotid surgery received as definitive therapy: (1) lateral lobectomy, (2) total parotidectomy, (3) radical parotidectomy without preoperative facial weakness, and (4) radical parotidectomy with preoperative facial weakness. Patients were assessed with regard to staging of the initial lesion, the status of surgical margins, and the use of postoperative radiotherapy. The incidence of local recurrence and distant metastases were also recorded. Survival statistics are presented for each group. Though associated with facial nerve sacrifice, radical parotidectomy appears to offer clear advantages in terms of long-term disease-free survival in patients with T2 and T3 lesions. The residual facial paralysis may be rehabilitated primarily or secondarily to reduce patient morbidity. Four of 16 patients (25%) with preoperative weakness achieved 10-year survival when radical parotidectomy was used. Obtaining clear margins at the initial setting appears to offer improved survival.

Induction chemotherapy for non-small cell lung cancer with clinically evident mediastinal node metastases: The role of postoperative radiotherapy

Survival for clinical Stage IIIa (T1–3, N2) non-small cell lung cancer is very poor because of poor local disease control and systemic spread. To address these shortcomings, we initiated a treatment program with induction chemotherapy, surgery, and postoperative radiation reserved for patients with residual disease at thoracotomy. Between 1984 and 1986, 41 patients with clinically evident N2 disease were treated with induction chemotherapy followed by resection and the selective use of intraoperative brachytherapy. All patients with tumor in the resection specimen received two cycles of chemotherapy and 15 patients received radiation therapy. With a median follow-up of 5.4 years, overall survival is 27% at 3 years, and 12% at 5 years. Despite the adverse selection process median survival is 19 months for patients receiving postoperative radiation therapy, and 22 months for the more favorable patients not requiring radiation therapy, supporting the selective use of postoperative radiation in this setting. In summary, this treatment has yielded good median survival and long-term survival for some of the patients. However, the ultimate value of this approach can only be determined by prospective trials which compare it to standard therapy.

Management of supratentorial low-grade gliomas

Low-grade gliomas are a clinically, radiographically, and pathologically diverse group of central nervous system neoplasms. Treatment decisions are based primarily on histologic tumor type and patient age. Pilocytic astrocytomas tend to occur in younger patients, are circumscribed, and amenable to cure with gross total resection. There is no role for the routine use of postoperative radiotherapy in these patients. In contrast, infiltrative tumors, including ordinary (nonpilocytic) astrocytomas, mixed oligoastrocytomas, and oligodendrogliomas occur in middle-aged patients and are generally not curable, even with gross total resection. Postoperative radiotherapy of these infiltrative tumors appears to improve survival, particularly in adults. Several ongoing clinical trials are addressing two issues: Observation vs radiotherapy and low-dose vs high-dose radiotherapy in patients with ordinary astrocytomas, oligoastrocytomas, and mixed oligoastrocytomas.

Have Changing Treatment Patterns Affected Outcome for Operable Breast Cancer? Ten-year Follow-up in 1288 Patients, 1965 to 1978

From 1965 to 1978, 1288 patients with primary operable breast cancer were treated by the senior author, using extended radical (ERM), radical (RM), and modified radical (MRM) mastectomy operations exclusively. Results were analyzed for trends in overall and disease-free survival, and patterns of local and distant relapse, the years 1965 to 1970 versus 1971 to 1974 versus 1975 to 1978. Significant changes (p less than 0.00001) from 1965 to 1978 included progressively earlier stage of disease, less frequent use of RM and ERM, a decline in the use of postoperative radiotherapy, and the introduction in 1975 of multidrug adjuvant chemotherapy. Ten-year disease-free survival rates improved significantly for all patients (by 11%, p = 0.00004) and for node-negative (by 12%, p = 0.0024), node-positive (by 8%, p = 0.012), clinical stage II (by 15%, p = 0.0022), and pathologic stage II (by 12%, p = 0.016) disease. Ten-year local recurrence for all patients was 3% (local only) and 2% (local with distant metastasis), and survival from date of recurrence for all patients failing treatment increased two times (p less than 0.0001) for patients treated most recently. As the primary surgical treatment of breast cancer continues to become more moderate, the promise of systemic adjuvant therapies can be realized only with continued emphasis on earlier diagnosis and maximal local control of disease.

Role of radiation after operative palliation in cancer of the proximal bile ducts

Cancer of the proximal bile ducts continues to pose a formidable problem to even the most experienced biliary surgeon. From 1977 through 1985, 51 patients with histologically confirmed proximal bile duct cancers underwent surgical treatment. The lesion was confined to the hilar region in 30 patients; there was extensive hepatic infiltration or distant metastatic disease in 21 patients. One patient underwent resection. Biopsy only was performed in six patients. In the remaining 44 patients, transtumoral dilation and intubation were performed. These 44 patients were further analyzed with regard to how survival was affected by the presence of metastatic disease and by the adjunctive use of radiation therapy. Mean survival in those patients with metastatic disease (n = 16) was 6.1 months, and survival was not improved by the use of postoperative radiation. In the absence of metastatic or advanced local disease, however, the addition of external beam radiation did significantly extend the mean survival from 4.5 to 12.2 months and the median survival from 2.2 to 12.2 months. The operative mortality for the series was 14% and postoperative complications occurred in 18 patients. These findings suggest that the addition of external beam radiation improves survival in patients undergoing palliative treatment of hilar tumors. Further confirmation of the value of radiation awaits prospective investigation.

Neck dessection: Concepts, Controversies, and Technique

The various types of neck dissections are described. The indications for each type of neck dissection are discussed for patients with necks staged N0, N+, for the patient with an unknown primary and for the patient whose neck dissection is in conjunction with radiation. The technical aspects of modified neck dissections are addressed but not in great detail. The indications for the use of postoperative radiation are emphasized. The nodal groups at risk for metastases from various primary sites are identified and a terminology for neck dissection is suggested.

Observations on the natural history and treatment of recurrent major salivary gland cancer

In an attempt to define the natural history and the indications for postoperative radiotherapy (RT) in locally recurrent major salivary gland cancers, we reviewed 78 patients treated between 1965 and 1982. All patients underwent resection of the tumor. Group 1 (N = 38) had complete resection of tumors, with low or intermediate grade histology and without lymph node spread. Group 2 consisted of the remaining 40 patients who had high-risk features (HR) (high grade histology, lymph node metastases, and close or positive margins of resection). Half of the Group 2 patients received radiation therapy. Overall survival was 63% at 5 years, and 35% at 15 years. Survival of Group 1 was 83% at 5 years and 58% at 15 years. Local control for Group 1 was 69% at 5 years, 54% at 15 years, and was size-dependent. Group 2 survival was 40% at 5 years and 29% at 10 years. Local control at 5 and 10 years was 49% and 35%. Our data indicate that surgery alone yielded good local control in patients with small tumors (less than or equal to 3 cm) and no HR features, suggesting that postoperative RT may be unnecessary for these patients. Other patients have suboptimal local control, and although there is a rationale for the use of postoperative radiotherapy, we cannot assess its impact in this retrospective study.

Critical Appraisal of Experimental Radiation Modalities for Malignant Astrocytomas

The management of patients with supratentorial malignant astrocytomas has remained a major problem. Patients continue to die from a lack of local control in 90% of cases despite an improvement of median survival seen with the use of postoperative radiation therapy. Because of this, there has been considerable interest in exploring novel ways of possibly improving results. This paper reviews the rationale and clinical results with the use of altered fractionation schemes, brachytherapy, radiation sensitizers, hyperthermia, particle therapy, and radiosurgery in the treatment of these patients. Currently, there is no demonstrated advantage with the use of these experimental modalities in the initial management of patients. There would appear to be some benefit for selected patients who are treated with brachytherapy at recurrence, but its efficacy as part of initial management remains to be determined determined in ongoing randomized prospective trials.

Controversies

The consultants agreed that dermatofibrosarcoma protuberans is characterized by its persistent growth and locally aggressive behavior. However, they did not all agree on the mode of treatment. Drs. Schuller and Snyderman favored surgical resection of the involved areas including the right cheek, lower eyelid, and any necessary portions of the nasal ala and upper lip. They encouraged the use of Moh's chemosurgery to detect microscopic disease. They were also in agreement regarding reconstruction, suggesting a cervical-facial or bi-lobed flap for the cheek. A full-thickness skin graft was recommended for the lower eyelid with primary closure planned for the lip defect. They disagreed on the use of postoperative radiation therapy. Dr. Schuller elected not to irradiate; Dr. Snyderman favored 60 to 65 Gy post-operatively. Dr. Quivey expressed concern regarding the morbidity from such a large resection and extensive reconstruction and suggested primary radiation therapy with external beam. All three consultants felt that good follow-up would include thorough head and neck examinations with MRI and/or CT scans if there were any concern about tumor recurrence.

The safe and effective use of postoperative radiation therapy in modified Astler Coller Stage C3 rectal cancer.

Locoregional recurrence in patients with Stage C3 (adjacent organ invasion) rectal carcinoma approaches 100% when surgery is not followed by adjuvant radiation therapy. The advent of the intestinal sling procedure (use of an absorbable polyglycolic acid mesh to suspend the small bowel out of the pelvis) has allowed tumoricidal doses (5000 cGy) of radiation therapy to be delivered to the pelvis without incurring radiation associated small bowel injury (RASBI). This surgical technique has allowed us to readdress the question, "what is the effectiveness of postoperative radiation therapy when tumoricidal doses can be safely administered to patients with Stage C3 rectal cancer?" Nineteen consecutive patients with Stage C3 rectal carcinoma underwent resective procedures and simultaneous use of the intestinal sling procedure. Postoperatively, all patients underwent contrast simulation studies that documented the small bowel above the sacral promentory. Tumoricidal doses ranging from 5200 to 5800 cGy (mean, 5600 cGy) were administered in fractionated doses. No patient demonstrated obstruction, infection, nausea, vomiting, cramps, diarrhea, or acute RASBI. There have been two locoregional recurrences in a mean follow-up period of 33 months (range, 12 to 54 months) in patients evaluated by physical examination, carcinoembryonic antigen (CEA) levels, computed axial tomography (CAT) scans, endoscopy, and reoperation or autopsy (P = 0.01). There have been ten distant recurrences (eight liver, one brain, and one lung). Three patients were reoperated on to rule out recurrence at 16, 17, and 24 months. All mesh was resorbed and there were no adhesions and no recurrent tumor. When the intestinal sling procedure is used, tumoricidal doses of radiation therapy can be safely administered without incurring RASBI. Postoperative high-dose radiation therapy can suppress locoregional recurrences in Stage C3 rectal carcinomas over and above what would be expected.

Rationale for elective modified neck dissection.

A retrospective study was conducted to give surgeons direction in deciding which type of modified neck dissection is proper elective treatment for the patient with a clinically negative neck. The medical records of 428 previously untreated patients (seen between January 1, 1970, and December 31, 1979) whose necks (i.e., NO) were electively dissected and who had had a primary squamous carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx were included. The three major types of modified neck dissections studied were the supraomohyoid, the anterior, and the functional. Sixteen percent (70 of 428) of the patients had multiple positive nodes and 6% (28 of 428) had evidence of extracapsular invasion. A unilateral supraomohyoid dissection was most often used for primaries of the oral cavity. Bilateral anterior dissection was common for cancers of the larynx and hypopharynx, and functional neck dissection was equally distributed among the primary sites. None of the patients with primaries of the larynx or hypopharynx had pathologically positive nodes in the submental or submaxillary triangles. Advanced T-stage was generally associated with a greater incidence of subclinically positive nodes. Thirty percent of the patients received postoperative radiotherapy. The total number of nodes removed, the number of positive nodes with or without extracapsular invasion, and the anatomic location of the positive nodes were correlated with the type of dissection, the stage and site of the primary cancer, the use of postoperative radiotherapy, the regional (neck) failure, and survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Multimodality Therapy and Distant Metastases: The Impact of Natural Killer Cell Activity

Stimson P. Shantz, MD, and Helmuth Goepfert, MD, of the Department of Head and Neck Surgery at the M. D. Anderson Hospital and Tumor Institute, Houston, discussed the impact of natural killer (NK) cell activity at the April 29, 1987 meeting of the American Society for Head and Neck Surgery. They noted that the use of postoperative radiotherapy for patients with head and neck cancer has been associated with an alteration in patterns of recurrence. Although this combined therapy regimen seems to reduce local recurrence, distant metastases predominate. The hypothesis is that factors contributing to this phenomenon may relate to the host immunologic status. There were 182 patients with previously untreated squamous cell carcinoma of the upper aerodigestive tract evaluated for NK cell activity. The initial definitive treatment rendered all of the patients disease free. These patients were subsequently followed up longitudinally with a median follow-up interval of 16 months.

Modified neck dissection

The medical records of 967 patients treated with a modified neck dissection were carefully reviewed, and the data were collected and statistically analyzed. For a primary tumor in the oral cavity or oropharynx, a supraomohyoid neck dissection was adequate treatment for the neck that was both clinically staged N0 or N1 and pathologically staged N1 without evidence of extracapsular invasion. For primary tumors in the larynx and hypopharynx, an elective bilateral anterior neck dissection is considered proper treatment if the nodes are not multiple or if connective tissue disease is not present. A functional neck dissection is effective neck treatment regardless of the primary site or stage of the disease. The selective use of postoperative radiotherapy can more effectively decrease the incidence of neck recurrence compared with surgery alone in patients with multiple positive nodes, a node more than 3 cm in size, or nodes with extracapsular invasion.

Omental transposition flap in colorectal carcinoma: Adjunctive use in prevention and treatment of radiation complications

The versatility of the omentum has led to its use as a surgical adjunct in the total oncological management of primary and recurrent colorectal carcinoma. The omentum is used as a transposition pedicle flap, broadly based on the left gastroepiploic vascular supply. Following abdominoperineal resection or low anterior resection of the rectum, the small bowel is elevated out of the pelvis by the omental bulk. The pelvic defect is reperitonealized and the risk of pelvic small bowel adhesions is diminished. With the increasing use of postoperative radiation to the pelvis for rectal carcinoma, the tolerance to therapy may be improved and the incidence of radiation enteritis and enteropathy should be reduced. Surgical complications such as leakage from low anterior anastomoses and pelvic abscesses, which may delay or contraindicate necessary postoperative radiation, are dramatically decreased. Reconstruction of the perineum with omental flap provides adequate soft tissue bulk and contour when a radical resection has been performed. The omentum has the potential for neovascular proliferation and can act to prevent inastomotic dehiscence of intestinal anastomoses involving previously irradiated bowel. Furthermore, covering unresectable recurrent carcinoma in the pelvis and retroperitoneum with the omentum as a palliative measure provides a thick anatomical barrier against potential ureteral, bladder, and small bowel invasion and obstruction. The omental flap has been used in 24 patients with colorectal carcinoma; one flap was lost as a result of distal omental infarction in a patient with recurrent rectal carcinoma and radionecrosis of the perinemn. The safety and ease of this procedure has allowed increased surgical innovation, especially in the prevention and treatment of radiation complications.

Tracheal stomal stenosis after laryngectomy.

Stenosis of the postlaryngectomy tracheal stoma remains a persistent problem. A retrospective study of 89 patients determined on overall incidence of 22 percent. The use of postoperative radiotherapy was associated with a higher incidence (36 percent) than preoperative radiotherapy (19 percent) and combined preoperative and postoperative radiotherapy (17 percent). Retention of the tracheal cannula for longer than 1 week was associated with a slightly increased incidence (25 percent) of stenosis. The technique of stomal construction was an important determinant of stoma stenosis. A simple circle of straight transection of the trachea had the highest incidence (29 percent) of stenosis, which could be reduced with a beveled technique (15 percent). The lowest incidence was seen with a primary plastic or flap construction technique (8 percent). The authors recommend the construction of a patulous stoma by a technique of beveling transection of the tracheal stump in combination with the use of interdigitation skin flaps.

The results of surgery and the selective use of postoperative radiotherapy in the treatment of cancer of the parotid gland

The results of surgery and the selective use of postoperative radiotherapy in the treatment of cancer of the parotid gland

Postoperative Radiation for Women with Cancer of the Breast and Positive Axillary Lymph Nodes

IT is unfortunate that arguments about the continuing use of postoperative radiation therapy in women with breast cancer and positive findings in the axillary nodes have not been widely discussed in this country. The controversy has generally been confined to specialty journals. A report of a recent National Cancer Institute consensus-development conference on the treatment of primary breast cancer delicately avoided the issue, and a recent review1 of the state of knowledge of cancer of the breast presented many pertinent data but yielded no conclusions about the value of postoperative radiation. However, a group of physicians at the National Cancer . . .

Malignant fibrous histiocytoma: a retrospective evaluation of 24 patients.

Twenty-four patients with malignant fibrous histiocytoma are being analyzed: 54.2% occurred in the sixth, seventh, and eighth decades of life; 45.8% were located in the extremities. This is a soft tissue sarcoma noted for its pleomorphic histologic appearance. It is postulated that the origin cell is a histiocyte. The local recurrence of metastatic potential of this tumor is difficult to predict from its histological features. Local recurrence after complete excision is frequent. Also, there is a high incidence of distant metastases. Wide local excision with a wide margin around the tumor is the most important treatment modality. The use of postoperative radiotherapy and chemotherapy needs to be evaluated.

Influence of postoperative empyema on survival after pulmonary resection for bronchogenic carcinoma.

Fifty patients who had developed empyema after pulmonary resection for primary carcinoma of the lung were individually paired with patients who had not suffered this complication. Pairs were matched as far as possible for age, sex, extent of operation, histology of tumour, extent of primary spread, extent of lymphatic spread, and use of postoperative radiotherapy. Analysis of survival times both for the matched pairs and for the two groups of patients showed no significant difference in long-term survival. The results suggest that any immunological suppression of carcinoma cells due to sepsis in the pleural space is ineffective in prolonging survival.