Surgery versus surgery and postoperative radiotherapy in squamous cell carcinoma of the buccal mucosa: a comparative study.
Department of Radiation Oncology, The Gujarat Cancer and Research Institute, Ahmedabad, India.
BACKGROUND: The efficacy of postoperative radiotherapy for squamous cell carcinoma of the buccal mucosa was evaluated. METHODS: One hundred seventy-six patients treated between 1989 and 1993 were analyzed. One hundred fifteen patients were treated with surgery alone (Group 1), and 61 patients were treated with a combination of surgery and postoperative radiotherapy (Group 2). RESULTS: Actuarial 3-year locoregional control in Groups 1 and 2 was 11% and 48% for patients with stage III + IV cancer (P =.001) and 71% and 75% for patients with stage I + II cancer (P =.74), respectively. On multivariate analysis for locoregional failure, surgical margin, bone invasion, high grade, and node involvement were significant factors in Group 1, whereas in Group 2 only tumor thickness was a significant factor. For local failure, margin, bone invasion, and stage in Group 1 and tumor thickness in Group 2 appeared as significant factors. For nodal failure, clinical nodal (cl N0 vs. N+) stage and grade in Group 1 and pathologic nodal stage (pN0 + 1 vs. pN2) in Group 2 were observed as significant factors. On subset analysis, postoperative radiotherapy was observed to have a significant advantage for surgical margins of 2 mm or less in both early pT (T1 + T2)(P =.019) and late pT (T3 + T4)(P =.016) stages. The local failure rate was higher if the time between surgery and radiotherapy was greater than 30 days. CONCLUSIONS: Postoperative radiotherapy was effective in decreasing locoregional failure in patients with close surgical margins, tumor thicker than 10 mm, high-grade tumors, positive node, and bone invasion. The effect of interval between surgery and postoperative radiotherapy on local failure was margin-dependent.
Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
BACKGROUND Lymph node density (LND) is superior to TNM nodal status in predicting survival after surgery for bladder and other cancers. Little is known, however, about whether LND can predict survival in patients with oral squamous cell carcinoma (OSCC). We therefore evaluated the utility of LND for predicting survival for patients with OSCC and positive nodes (pN+). METHODS We reviewed the clinical, pathologic, and follow-up data of 211 OSCC patients who underwent surgery. All lymph nodes harvested from neck dissection were carefully examined, with LND calculated as the ratio of positive lymph nodes to total lymph nodes removed. Univariate and multivariate analyses of variables predicting overall survival (OS) and disease-specific survival (DSS) were performed for all patients and in pN+ patients. RESULTS Kaplan-Meier analyses showed that the 5-year OS and DSS rates in all patients were 72% and 79%, respectively. Multivariate analysis showed that variables independently prognostic for DSS were T classification (hazard ratio [HR]= 2.97, 95% confidence interval [95% CI]= 1.59-5.57; P =.001), and N classification (HR = 4.91, 95% CI = 2.47-9.75; P <.001). In pN+ patients, univariate analysis showed that T classification,>2 positive nodes, and LND >0.06 (median) were significant predictors of DSS (P <.015 each), and multivariate analysis showed that LND was an independent predictor of DSS (HR = 3.24, 95% CI = 1.61-6.53; P =.001). CONCLUSIONS LND may be useful in stratifying the likelihood of survival in patients with OSCC.
Jih-Chuan Jan, Wu-Huei Hsu, Shih-An Liu, Yong-Kie Wong, Chiu-Kwan Poon, Rong-San Jiang, Jian-Sheng Jan, I-Fan Chen
Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan.
Squamous cell carcinoma (SCC) of the buccal mucosa accounts for 23% to 37% of all intraoral cancer cases in Taiwan. Because of the high recurrence rate and invasive tumor behavior, the prognosis is generally poor. The aim of this study was to evaluate the prognostic significance of clinicopathologic factors on survival rates for patients with buccal SCC in a medical center in central Taiwan. Between March 1995 and December 2002, patients admitted to hospital and diagnosed as having buccal SCC were enrolled in the study. There were 415 patients (406 men and 9 women) 25 to 84 years old (mean age, 51.1 ± 11.4 years). The chart records were retrospectively reviewed. Relevant clinical features in each patient, such as primary tumor size, tumor stage, initial treatment modalities, surgical margin status, cervical nodal metastasis status, and histopathologic grade, were compared for survival analysis. Three hundred ninety-four patients received surgical intervention. Univariate analysis of relevant prognostic factors showed that positive surgical margin, positive cervical nodal metastasis, positive extracapsular spread, larger tumor, and advanced tumor stage were associated with poor prognosis. Multivariate analysis identified the factors that independently influenced the survival rate as advanced stage disease (stage III: relative risk [RR], 3.09; P =.006; stage IV: RR, 4.64; P <.001), positive surgical margin (RR, 2.02; P =.001), and extracapsular spread of cervical lymph node metastasis (RR, 6.89; P <.001). This study represents the largest series in the literature and highlights the importance of tumor stage, surgical margin status, and extracapsular spread of cervical nodal metastasis as the most important prognostic factors in patients with buccal SCC.
Johannes A Langendijk, Alfio Ferlito, Robert P Takes, Juan P Rodrigo, Carl Suárez, Primo Strojan, Missak Haigentz Jr, Alessandra Rinaldo
Department of Radiation Oncology, University Medical Center Groningen/University of Groningen, Groningen, The Netherlands. firstname.lastname@example.org
This review discusses the role of adjuvant treatment after curative surgery for patients with head and neck squamous cell carcinoma (HNSCC). In general, patients with unfavourable prognostic factors have a high-risk of loco-regional recurrence and subsequent worse survival after surgery alone and are therefore considered proper candidates for adjuvant treatment by either postoperative radiotherapy alone or postoperative chemoradiation. Selection of the most optimal adjuvant treatment strategy should be based on the most important prognostic factors. In this review, the different treatment strategies will be discussed in general. More specifically, we will discuss the role of the interval between surgery and radiotherapy, the overall treatment time of radiation, the selection of target volumes for radiation and the value of adding concomitant chemotherapy to postoperative radiation.
Short delay in initiation of radiotherapy may not affect outcome of patients with glioblastoma: a secondary analysis from the radiation therapy oncology group database.
Deborah T Blumenthal, Minhee Won, Minesh P Mehta, Walter J Curran, Luis Souhami, Jeff M Michalski, C Leland Rogers, Benjamin W Corn
Departments of Oncology, Tel Aviv Medical Center, Tel Aviv, Israel. email@example.com
PURPOSE To analyze the Radiation Therapy Oncology Group (RTOG) database of patients with glioblastoma and appraise whether outcome was influenced by time to initiation of radiation therapy (RT). PATIENTS AND METHODS From 1974 through 2003, adult patients with histologically confirmed supratentorial glioblastoma were enrolled onto 16 RTOG studies. Of 3,052 enrolled patients, 197 patients (6%) were either initially rendered ineligible or had insufficient chronologic data, leaving a cohort of 2,855 patients for the present analysis. We selected four patient groups based on the interval from surgery to the start of RT:<or= 2 weeks, 2 to 3 weeks, 3 to 4 weeks, more than 4 weeks to the protocol eligibility limit of 6 weeks. Survival times were estimated by the Kaplan-Meier method. Multivariate analysis incorporated variables of time interval, recursive partitioning analysis (RPA) class, and treatment regimen. RESULTS No decrement in survival could be identified with increasing time to initiation of RT. Among our four temporal groupings, median survival time was unexpectedly and significantly greater in the group with the longest interval (> 4 weeks) than in those with the shortest delay (<or= 2 weeks): respectively, 12.5 months versus 9.2 months (P <.0001). On multivariate analysis, with overall survival as the end point, time interval more than 4 weeks and lower RPA class were both significant predictors of improved outcome. Treatment regimen was not a significant factor. CONCLUSION There is no evident reduction in survival by delaying initiation of RT within the relatively narrow constraint of 6 weeks. An unanticipated yet significantly superior outcome was identified for patients for whom RT was delayed beyond 4 weeks from surgery.
When does skin excision allow the achievement of an adequate local control rate in patients with squamous cell carcinoma involving the buccal mucosa?
Chun-Ta Liao, Shiang-Fu Huang, I-How Chen, Joseph Tung-Chieh Chang, Hung-Ming Wang, Shu-Hang Ng, Chuen Hsueh, Li-Yu Lee, Chih-Hung Lin, Ann-Joy Cheng, Tzu-Chen Yen
Department of Otorhinolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.
BACKGROUND The role of cheek skin excision in patients with squamous cell carcinoma of the buccal mucosa (BSCC) remains controversial. We sought to investigate when skin excision is needed to achieve an adequate local control. METHODS A total of 331 patients with BSCC were reviewed. Skin preservation was pursued when the distance between the tumor and the skin as determined by imaging was >or=13 mm (1 cm surgical margin plus 0.3 cm skin preservation). Two hundred and thirty patients (69.5%) underwent skin excision. Postoperative adjuvant radiotherapy (n = 182) was performed in patients with pathological T4 disease, metastases in cervical lymph nodes or close pathological margins (<or=4 mm). The 5-year local control rate was plotted by Kaplan-Meier analysis. RESULTS Twenty-four patients (7.3%) had close pathological margins. The 5-year local control rate did not differ significantly between patients treated either with or without skin excision. This was verified both in subjects who received surgery alone (94% versus 91%) and in those who received surgery plus adjuvant therapy (82% versus 86%). CONCLUSION In patients with BSCC, a good 5-year local control rate may be equally achieved either with or without skin excision. In patients with pT3 disease, postoperative radiotherapy is not recommended in the absence of close pathological margins. Our findings may guide clinical decision-making on skin excision in this patient group.
Treatment outcome of combined modalities for buccal cancers: unilateral or bilateral neck radiation?
Chien-Yu Lin, Li-Yu Lee, Shiang-Fu Huang, Chung-Jan Kang, Kang-Hsing Fan, Hung-Ming Wang, Eric Yen-Chao Chen, I-How Chen, Chun-Ta Liao, Ann-Joy Cheng, Joseph Tung-Chieh Chang
Department of Radiation Oncology, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
PURPOSE To evaluate the outcome of treatment for buccal cancers and assess the impact of unilateral vs. bilateral adjuvant neck radiation. METHODS AND MATERIALS We retrospectively reviewed the course of 145 patients newly diagnosed with buccal squamous cell carcinoma without distant metastases who completed definitive treatment between January 1994 and December 2000. Of 145 patients, 112 (77%) had Stage III or IV disease. All underwent radical surgery with postoperative radiotherapy (median dose, 64 Gy), including unilateral neck treatment in most (n = 120, 82.8%). After 1997, cisplatin-based concomitant chemoradiotherapy was given for high-risk patients with more than two involved lymph nodes, extracapsular spread, and/or positive margins. RESULTS The 5-year disease-specific survival rate for Stages I-IV was 87%, 83%, 61%, and 60%, respectively (p = 0.01). The most significant prognostic factor was N stage, with the 5-year disease-specific survival rate for N0, N1, and N2 being 79%, 65%, and 54%, respectively (p = 0.001). For patients with more than two lymph nodes or positive extracapsular spread, cisplatin-based concomitant chemoradiotherapy improved locoregional control (p = 0.02). Locoregional control did not differ between patients undergoing unilateral or bilateral neck treatments (p = 0.95). Contralateral neck failure occurred in only 2.1%. CONCLUSIONS In patients with buccal carcinoma after radical resection, ipsilateral neck radiation is adequate. Bilateral prophylactic neck treatment does not confer an added benefit.
The relationship between waiting time for radiotherapy and clinical outcomes: a systematic review of the literature.
Queen's Cancer Research Institute, Queen's University, Kingston, Ontario, Canada.
PURPOSE To synthesize the direct clinical evidence relating waiting times (WTs) for radiotherapy (RT) to the outcomes of RT. METHODS AND MATERIALS We did a systematic review of the literature between 1975 and 2005 to identify clinical studies describing the relationship between WTs and outcomes of RT. Only high quality (HQ) studies that had adequately controlled for confounding factors were included in the primary analysis. WTs that had originally been reported as a categorical variable were converted to a continuous variable based on the distribution of WTs in each category. Meta-analyses were done using a fixed-effect model. RESULTS The systematic review identified 44 relevant studies. Meta-analyses of 20 HQ studies of local control demonstrated a significant increase in the risk of local failure with increasing WT, RRlocal recurrence/month =1.14, 95% Confidence Intervals (CI): 1.09-1.21. For post-operative RT for breast cancer; RRlocal recurrence/month =1.11, 95%CI: 1.04-1.19. For post-operative RT for head and neck cancer, RRlocal recurrenc/month =1.28, 95%CI: 1.08-1.52. For definitive RT for head and neck cancer, RRlocal recurrence/month =1.15, 95%CI: 1.02-1.29. There was little evidence of any association between WTs and the risk of distant metastasis. Meta-analyses of the 6 HQ studies of breast cancer showed RRmetastasis/month =1.04, 95%CI: 0.98-1.09. Meta-analyses of 4 HQ studies of breast cancer showed no significant decrease in survival with increasing WT, RRdeath/month =1.06, 95%CI: 0.97-1.16, but there was a marginally significant decrease in survival in 4 HQ studies of head and neck cancer, RRdeath/month =1.16, 95%CI: 1.02-1.32. CONCLUSIONS The risk of local recurrence increases with increasing WTs for RT. The increase in local recurrence rate may translate into decreased survival in some clinical situations. WTs for RT should be as short as reasonably achievable.
Clinicopathologic evaluation of prognostic factors for squamous cell carcinoma of the buccal mucosa.
Department of Otolaryngology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan. R.O.C.
BACKGROUND The purpose of this research was to evaluate the prognostic significance of clinicopathologic variables on the survival rate for squamous cell carcinoma of the buccal mucosa (BMSCC). We analyzed the outcomes of surgical therapy for this aggressive cancer and compared these results with those in the literature. METHODS We reviewed the medical charts of 172 patients treated in our institution between 1990 and 2005. There were 22 patients excluded from our studies: 20 patients with advanced tumors who received no treatment or palliative treatment, and 2 patients who had received preoperative radiotherapy (RT). The remaining 150 patients were treated with surgeries and among them, 56 patients had undergone postoperative RT. The influence of clinicopathologic factors on the survival rate was analyzed with the Kaplan-Meier method and log-rank test. Multivariate analysis was assessed with Cox's regression model. RESULTS There were 148 males and 2 females, with a mean age of 53.5 years. The prevalence rate of habitual betel quid chewing documented in charts among 113 patients was 75%. The 5-year overall survival rate and disease-specific survival rate for all patients were 64% and 69%, respectively. For patients with stages I, II, III, and IV disease, the 5-year disease-specific survival rates were 90%, 77%, 52%, and 47%, respectively (p<0.001). According to the multivariate analysis, the pathologic staging and histologic grading of the tumor were independently the important prognostic factors affecting survival rate. There were 80 patients who developed locoregional recurrence in lymph nodes in the follow-up diagnoses. Distant metastases occurred in 14 patients, with 11 of them also having locoregional recurrence. The distant metastases were found in the lungs (8/14), T-spine (3/14), liver (2/14) and brain (1/14). CONCLUSION Pathologic stage and histologic grade are the most important prognostic factors.
Radiation Therapy Program of the B.C. Cancer Agency, Fraser Valley Centre, Surrey, British Columbia, Canada. firstname.lastname@example.org
PURPOSE The aim of this study was to investigate whether a delay in radiotherapy is associated with a poorer biochemical control for prostate cancer. METHODS The time to treatment (TTT) from diagnosis of prostate cancer to radiotherapy was analyzed with respect to prostate-specific antigen (PSA) control in 1024 hormone-naive patients. The Kaplan-Meier PSA control curves for patients with TTT less than the median were compared with those for patients with TTT greater than the median in 3 predefined risk groups. Statistical significant differences in PSA control were further analyzed using Cox multivariate analysis with pretreatment PSA, Gleason score, T stage, and radiotherapy dose as covariates. RESULTS The median TTT and median follow-up are 3.7 months and 49 months respectively. Patients with a longer TTT have a statistically significant better PSA control than patients with a shorter TTT if they have intermediate- or high-risk disease. However in multivariate analysis TTT was not found to be significant in predicting PSA control, with pretreatment PSA and Gleason score emerging as highly significant in predicting PSA failure in both intermediate- and high-risk disease. CONCLUSION In this study in prostate cancer patients in British Columbia, there was no evidence that a longer time interval between diagnosis and radiotherapy was associated with poorer PSA control.
Department of Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Records of 100 consecutive cases of carcinoma of the buccal mucosa treated in our institute between January 2000 and December 2003 were analyzed for clinical presentation, patterns of care, disease-free survival (DFS) and prognostic factors. There were 75 males and 25 females. The mean age was 50 years. Ninety five gave a history of abuse of oral tobacco products. Only 20 patients were in Stage I or II. Sixty one patients had Stage IV disease. Sixty six patients were treated with radical intent while 34 were suitable only for palliative radiation. The 2-year DFS for the entire group was 47.94%. All failures occurred by 12 months. However, the 2-year DFS in radically treated patients was 76.4%. On univariate analysis, late overall stage, T3/T4 disease, node positivity and palliative treatment were significant poor prognostic factors. On multivariate analysis, T3/T4 disease and palliative treatment were independent poor prognostic factors. Early detection can improve outcomes considerably in this disease.
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Department of Radiotherapy, Gujarat Cancer and Research Institute, Ahmedabad, India.
Thirty seven cases (30 males; 7 females) of advanced non-small cell lung cancer were treated with short course of palliative radiotherapy. All the patients were inoperable. Their main symptoms were related to primary intrathoracic disease and poor performance status. Radiotherapy was delivered to a total dose of 17 Gy in two fractions one week apart. Ninety percent of the patients had cough, 50% complained of haemoptysis, 45% chest pain and 30% breathlessness. Palliation of main symptoms was achieved in majority of the patients, more than 90% in haemoptysis, 60% in cough, 70% in chest pain and 50% in breathlessness. Mean duration of palliation was four months and performance status improved in 60% of the patients. Short course radiotherapy of 17 Gy in two weekly fractions is recommended in patients with advanced non-small cell lung cancer (NSCLC) having poor performance status.
Department of Radiotherapy, Gujarat Cancer and Research Institute, Ahmedabad, India.
A retrospective analysis of 165 patients with Stage 3 B carcinoma of the cervix treated with radiotherapy alone was done; 120 patients were treated with a combination of external radiotherapy and intracavitary treatment while 45 patients received external radiotherapy only. Early rectosigmoid reactions were seen in 65% of cases with Grade 1, 2 and 3 reactions in 40%, 20% and 5% of cases respectively. Late rectosigmoid sequelae were observed in 25 patients (16%) with moderate complications in 5%. Severe rectal complications were seen in 2 women only. Rectosigmoid complications are the most common sequelae of pelvic irradiation and seen more in advanced stages where a greater dose is given by external radiotherapy. The role of rectal dosimetry is equivocal if proper precautions are taken during intracavitary treatment.
Department of Radiotherapy, Gujarat Cancer & Research Institute, Ahmedabad, India.
Fifty-six patients with stage I testicular seminoma were treated at this institute between January 1982 and December 1988. Post-orchiectomy elective radiotherapy to ipsilateral iliac-inguinal and para-aortic lymph nodes was delivered in 54 cases. An overall 3 year survival rate of 96% was observed in this series. Four patients (7%) relapsed (one junctional recurrence in iliac node region, two mediastinal/hilar nodes and one skeletal metastasis). Salvage chemotherapy proved successful in two out of three cases with nodal relapse. No dose limiting acute or late radiation related complications were noticed. No definite correlation was found between the patients who relapsed and various known adverse prognostic factors. We recommend elective irradiation of the draining lymph nodes in stage I seminoma, particularly at centres where surveillance is not feasible.
Department of Radiotherapy, Gujarat Cancer and Research Institute, Ahmedabad.
In order to predict possibility of local control in carcinoma of the oesophagus by radiotherapy, the relationship between the x-ray findings before and after radiotherapy were analyzed in 55 irradiated cases. In the superficial or proliferative type on x-ray before treatment, local control was observed in 87% cases with dose of 40 Gy, whereas in the ulcerative or infiltrative type it was observed in 20% cases. Radiation response is remarkably good in proliferative and superficial lesions seen in oesophagogram.
Dept of Radiation Oncology, Gujarat cancer and Research Institute, New Civil Hospital Compound, Asarwa, Ahmedabad.
A diagnosis of leiomyosarcoma of ovary was made in a 60 year old female presenting with generalised weakness and abdominal lump. On clinical examination, a hard, big mass with some cystic areas was found occupying the pelvic cavity. Chest X-ray revealed presence of metastases. Deranged renal function and structure due to extrinsic pressure were evident on pyelography and USG. USG also suggested the ovarian origin of the mass. Fine needle aspiration biopsy was suggestive of leiomyosarcoma. Laparotomy was carried out for excision of tumor along with bilateral salpingo-oophorectomy and hysterectomy. Post-operatively renal functions normalized. A course of radiotherapy was given. At 6 months' follow-up, abdomino-pelvic sonography was normal but lung metastases were found to be enlarged. The patient was asked to follow up for chemotherapy but did not come. She died 18 months after treatment, as revealed through correspondence.
Department of Radiation Oncology, Gujarat Cancer & Research Institute, Ahlmedabad, India.
Twenty eight patients with stage II A and twenty patients with stage II B testicular seminoma were treated at this institute between January 1982 and December 1988. The three year crude survival observed in this retrospective analysis was 82% and 75% respectively. Post orchiectomy infradiaphragmatic radiotherapy was the mainstay of the treatment. In stage II A 4 patients were administered adjuvant chemotherapy as well. Prophylactic Mediastinal Irradiation (PMI) was not employed as a routine in this subgroup. Eight patients (28%) relapsed (Mediastinal Nodes--4, Pulmonary--3, Scrotal--1). In stage II B twelve patients were treated with primary abdominal radiotherapy and of them 4 were delivered PMI as well. Induction chemotherapy was administered in remaining 8 patients. Seven patients (35%) relapsed (Pulmonary-4, Mediastinal Nodes-3). Mediastinal recurrence was noted only in those who were treated with abdominal radiotherapy alone. Though salvage chemotherapy proved successful in 5 of the seven patients (70%) with nodal relapse, none of the patients with extranodal relapse responded to subsequent chemotherapy. For stage II A we recommend abdominal radiotherapy alone and for stage II B Induction chemotherapy is advised keeping radiotherapy reserved for residual mass. We do not advocate PMI as a routine in stage II testicular seminoma as no survival benefit is observed.
Role of pretherapeutic biomarkers in predicting postoperative radiotherapy response in patients with advanced squamous cell carcinoma.
Biochemistry Research Division, Department of Cancer Biology, The Gujarat Cancer and Research Institute, NCH Campus, Asarwa, Ahmedabad-380 016, India.
PURPOSE To assess the role of biomarker levels in predicting radiotherapy (RT) response in patients with squamous cell carcinoma of buccal mucosa treated with postoperative RT. MATERIALS AND METHODS Thirty-one patients with squamous cell carcinoma of buccal mucosa who received postoperative RT were enrolled for the study. Glutathione S-transferase (GST), glutathione reductase (GR), superoxide dismutase (SOD) and catalase activity were analysed from primary tumour and adjacent normal mucosa of the same patients before RT. p53 and p21ras were localized immunohistochemically. RESULTS Enzyme activation was predicted by comparing the levels of these enzymes in tumour and adjacent normal mucosa. Deactivation of GST, activation of GR, SOD and catalase were associated with poor response to RT. p53 immunoreactivity was associated with failure to respond to RT. CONCLUSIONS These markers may be useful in predicting treatment outcome in patients receiving postoperative RT, although this conclusion requires confirmation in a larger group of patients.
Department of Radiotherapy, Gujrat Cancer & Research Institute, Ahmedabad, Gujrat.
An interesting case of plasmacytoma of the scalp is described. Extramedullary plasmocytoma of scalp is rarely reported. This patient was treated with external radiotherapy dose of which was 40 Gy/20 fraction. Disease responded very well to radiotherapy.
Dept of Radiotherapy, Gujarat Cancer and Research Institute, Asarwa Ahmedabad.
Adenoid cystic carcinoma of the cervix is a rare disease. It usually occurs in an elderly age group. A case who presented at a younger age (30 years) is being reported. The chief complaint was excessive vaginal bleeding for 2 months. Per vaginum examination revealed a growth. She was staged FIGO IIIb. She was treated with radical radiotherapy. Disease regressed slowly and complete local response appeared after six months of treatment. Presentation of adenoid cystic carcinoma in younger age group and effect of radiotherapy in advanced stage is reviewed.
Department of Radiotherapy, Gujarat Cancer & Research Institute, Ahmedabad, India.
Seventy cases of squamous cell carcinoma of the vagina registered between 1985 and 1989 were analyzed. The overall 2-year disease-free survival was 33%. Stagewise 2-year survivals were as follows: stage I, 100%(8/8); stage II, 70%(7/10); stage III, 19%(8/42); and stage IV, 0%(0/10). Incidentally, 60% of the cases presented below 50 years of age, and the majority of these were in advanced stage (p < 0.02). Due to the relatively greater number of cases of advanced disease in the elderly age group treated with external radiotherapy alone, a significant survival difference between the two age groups was not apparent (P > 0.10). External radiotherapy alone yielded poor results. External radiotherapy in combination with brachytherapy in the form of either vaginal cylinders or uterine tandems with vaginal cylinders resulted in 42 and 50% 2-year disease-free survivals, respectively. Advanced stage, more than two-thirds to full vaginal length involvement, and multiple vaginal wall involvement were found to be poor prognostic factors. The majority of cases had tumor grades 2 and 3. No association between tumor grade and survival was observed. To improve survival, downstaging of the disease through routine gynecological checkup, even in premenopausal women, and delivery of high doses through a judicious combination of external radiotherapy and brachytherapy are needed.
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Laryngoscope. 2012 Jun 11;: 22689284
Gideon Bachar, David P Goldstein, Emma Barker, Jane Lea, Brian O'Sullivan, Dale H Brown, Patrick J Gullane, Ralph W Gilbert, Wei Xu, Jie Su, Jonathan C Irish
Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology , Toronto, Ontario, Canada.
OBJECTIVES/HYPOTHESIS: The objective of this study was to analyze the patterns of failure and to determine clinical and pathologic factors predictive of recurrence and survival of patients treated for squamous cell carcinoma of the buccal mucosa at Princess Margaret Hospital. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review of patients treated for buccal carcinoma between 1994 and 2004 was performed. Seventy patients with newly diagnosed and previously untreated squamous cell carcinoma of the buccal mucosa were included. Demographic, clinical, and pathological parameters were identified and correlated with outcomes. RESULTS: The patient cohort consisted of 33 males and 37 females. Most patients presented with early-stage local disease (T1-T2). Surgery was the primary treatment in 61 patients. Twenty-three patients were treated with postoperative radiotherapy. Median follow-up was 3.3 years. The 5-year local, regional, and overall control rates were 57.5%, 83.5%, and 50%, respectively. The 5-year overall survival rate was 69%. The 5-year disease-specific and recurrence-free survival rates were 76.4% and 46%, respectively. The only significant predictors of survival were the nodal status and extranodal extension. CONCLUSIONS: Carcinoma of the buccal mucosa is an aggressive disease, characterized by a high rate of locoregional failure. Transoral wide excision is an adequate treatment for early-stage lesions; however, a combined approach and an elective neck dissection should be considered in advanced lesions. Laryngoscope, 2012.
Long-term Outcomes and Quality of Life of 186 Patients with Primary Parotid Carcinoma Treated with Surgery and Radiotherapy at the Daniel den Hoed Cancer Center.
Department of Radiation Oncology, Erasmus Medical Center-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
PURPOSE: To assess the outcomes, toxicity, and quality of life (QOL) of patients with primary parotid carcinoma treated with surgery and postoperative radiotherapy at the Daniel den Hoed Cancer Center. METHODS AND MATERIALS: Between 1995 and 2010, 186 patients with parotid carcinoma were treated with parotidectomy with or without neck dissection, followed by radiotherapy. Elective nodal irradiation (ENI) was applied to high-risk, node-negative disease. End points were locoregional control (LRC), disease-free survival (DFS), cause-specific survival (CSS), and overall survival (OS), late toxicity, and QOL. RESULTS: After a median follow-up of 58 months (range, 4-172 months), the 5-year Kaplan-Meier estimates for LRC, DFS, CSS, and OS were 89%, 83%, 80%, and 68%, respectively. Forty-five events were reported: 24 distant metastases (DM) and 21 locoregional failures (LRF). Event-free survival rates by histological types were 89%, 78%, 76%, 74%, and 70% for acinic cell, mucoepidermoid, adenoid cystic, adenocarcinoma, and squamous cell carcinoma, respectively. More LRF were reported in patients with squamous cell and high-grade mucoepidermoid carcinoma (21% and 19%, respectively) than in patients with other histological types (p = 0.04) and more DM in patients with adenoid cystic and adenocarcinoma (20% and 19%, respectively) than in patients with other types (p = 0.03). None of the high-risk node-negative patients who received ENI developed regional failure. On multivariate analysis, T stage, N stage, grade, and presence of perineural invasion and facial paralysis correlated significantly with DFS. The 5-year cumulative incidence of grade ≥2 late toxicity was 8%. QOL scores deteriorate during and shortly after treatment but returned in almost all scales to baseline scores within 6 months. CONCLUSIONS: Of the entire group, surgery and postoperative radiotherapy resulted in excellent outcomes with minimal side effects and preservation of good QOL scores. However, in view of the pattern of failures observed in this study, the role of adjuvant systemic or targeted therapy in patients at high risk of DM should be investigated in prospective trials.
J Oncol. 2012 ;2012 :391917 22315594
Definitive Radiotherapy versus Postoperative Radiotherapy of Patients with Oro- and Hypopharyngeal Cancer: Impact of Prognostic Factors.
Department of Radiation Oncology, University of Heidelberg, Heidelberg 69120, Germany.
Purpose. To compare the impact of prognostic factors of patients treated with definitive radio(chemo)therapy versus patients treated with surgery and postoperative radiotherapy for squamous cell carcinoma of the oro- and hypopharynx. Patients and Methods. 162 patients treated with definitive radiotherapy and 126 patients treated with postoperative radiotherapy were retrospectively analysed. The impact of the prognostic factors gender, age, total tumor volume (TTV), pre-radiotherapy hemoglobin level (Hb-level), tumor site, T- and N-classification, radiotherapy interruptions >5 days, radiotherapy versus simultaneous radiochemotherapy, R-status and time interval between surgery and radiotherapy were investigated. Results. The median follow-up time for the censored patients treated with definitive radio(chemo)therapy was 28.5 months and for postoperative radiotherapy 36.5 months. On univariate analysis, the TTV, Hb-level, and simultaneous radiochemotherapy had a significant impact on the survival of patients treated with definitive radio(chemo)therapy. For patients treated with postoperative radiotherapy, only the TTV showed a statistical trend for the survival (P = 0.13). On multivariate analysis, the TTV and simultaneous radiochemotherapy maintained their statistical significance for patients treated with definitive raditherapy, and the TTV, the statistical trend for patients treated with postoperative radiotherapy (P = 0.19). Conclusions. The TTV was the predominant prognostic factor for both, patients treated with definitive or postoperative radiotherapy.
Head Neck. 2012 Jan 20;: 22266920
Chun-Shu Lin, Yee-Min Jen, Woei-Yau Kao, Ching-Liang Ho, Ming-Shen Dai, Chia-Lin Shih, Jen-Chan Cheng, Ping-Ying Chang, Wen-Yen Huang, Yu-Fu Su
Department of Radiation Oncology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. email@example.com.
BACKGROUND: The treatment results of buccal squamous cell carcinoma before and after 2002 were compared. METHODS: Two hundred forty-five patients with buccal cancer who underwent curative treatment were retrospectively reviewed. RESULTS: The 5-year overall survival rate was 30.0% before 2002 and 53.5% after 2002 (p =.004). On multivariate analysis, T classification, surgical margins, and treatment modality significantly affected overall survival, and N classification and histologic grade had trends to affect it. Invasion depth had a trend to influence locoregional control. For patients with early-stage disease without adverse factors, the locoregional control was similar between surgery alone group and surgery + radiotherapy group. CONCLUSION: The survival of patients with buccal cancer was improved after 2002, which represented the start of intensity-modulated radiotherapy (IMRT) in our institute. Ipsilateral neck alone irradiation was recommended for T1-2N0-1 and small T3N0 disease, and bilateral neck irradiation could be reserved for advanced disease. © 2012 Wiley Periodicals, Inc. Head Neck, 2012.
Am J Clin Oncol. 2011 Jun 8;: 21659832
Kyubo Kim, Eui Kyu Chie, Jin-Young Jang, Sun Whe Kim, Do-Youn Oh, Seock-Ah Im, Tae-You Kim, Yung-Jue Bang, Sung W Ha
Departments of *Radiation Oncology †Surgery ‡Internal Medicine, Seoul National University College of Medicine §Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Republic of Korea.
OBJECTIVES: To compare the treatment outcome of surgery alone with that of surgery followed by adjuvant chemoradiotherapy (CRT) for duodenal cancer. METHODS: Between January 1991 and December 2002, 24 patients with duodenal cancer underwent pancreaticoduodenectomy. There were 14 males and 10 females, and median age was 61 years (range, 33-75). Nine patients received adjuvant CRT, and 15 did not. Postoperative radiotherapy was delivered up to 40 Gy at 2 Gy/fraction with a 2-week planned rest. Intravenous 5-fluorouracil (500 mg/m/d) was given on days 1 to 3 of each split course. Median follow-up period was 32 months (range, 5-170). RESULTS: Nodal stage and stage group were more advanced in CRT (+) group (P=0.0894 and 0.0361, respectively). However, other patient and tumor characteristics were similar in each group. Five-year overall survival rates of CRT (-) and CRT (+) group were 47% and 30%, respectively (P=0.3799). Five-year locoregional relapse-free survival rates of CRT (-) and CRT (+) group were 64% and 80%, respectively (P=0.4188). On multivariate analysis, patients treated with adjuvant CRT had better locoregional relapse-free survival with borderline significance (P=0.0750). No patient suffered grade 3 or higher toxicity during CRT. CONCLUSIONS: Adjuvant CRT is feasible and may enhance locoregional control in advanced-staged duodenal cancer after curative resection.
Intensity-modulated radiotherapy for oral cavity squamous cell carcinoma: patterns of failure and predictors of local control.
Megan E Daly, Quynh-Thu Le, Margaret M Kozak, Peter G Maxim, James D Murphy, Annie Hsu, Billy W Loo Jr, Michael J Kaplan, Nancy J Fischbein, Daniel T Chang
Department of Radiation Oncology, Stanford University Medical Center, Stanford, CA 94305, USA.
PURPOSE Few studies have evaluated the use of intensity-modulated radiotherapy (IMRT) for squamous cell carcinoma (SCC) of the oral cavity (OC). We report clinical outcomes and failure patterns for these patients. METHODS AND MATERIALS Between October 2002 and June 2009, 37 patients with newly diagnosed SCC of the OC underwent postoperative (30) or definitive (7) IMRT. Twenty-five patients (66%) received systemic therapy. The median follow-up was 38 months (range, 10-87 months). The median interval from surgery to RT was 5.9 weeks (range, 2.1-10.7 weeks). RESULTS Thirteen patients experienced local-regional failure at a median of 8.1 months (range, 2.4-31.9 months), and 2 additional patients experienced local recurrence between surgery and RT. Seven local failures occurred in-field (one with simultaneous nodal and distant disease) and two at the margin. Four regional failures occurred, two in-field and two out-of-field, one with synchronous metastases. Six patients experienced distant failure. The 3-year actuarial estimates of local control, local-regional control, freedom from distant metastasis, and overall survival were 67%, 53%, 81%, and 60% among postoperative patients, respectively, and 60%, 60%, 71%, and 57% among definitive patients. Four patients developed Grade ≥ 2 chronic toxicity. Increased surgery to RT interval predicted for decreased LRC (p = 0.04). CONCLUSIONS Local-regional control for SCC of the OC treated with IMRT with or without surgery remains unsatisfactory. Definitive and postoperative IMRT have favorable toxicity profiles. A surgery-to-RT interval of < 6 weeks improves local-regional control. The predominant failure pattern was local, suggesting that both improvements in target delineation and radiosensitization and/or dose escalation are needed.
Radiat Oncol. 2010 ;5 :43 20504371
Clinical outcomes for T1-2N0-1 oral tongue cancer patients underwent surgery with and without postoperative radiotherapy.
Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea.
Prognostic factors for loco-regional failure in early stage (I and II) squamous cell carcinoma of the gingivobuccal complex.
Rohan R Walvekar, Devendra A Chaukar, Mandar S Deshpande, Prathamesh S Pai, Pankaj Chaturvedi, Anagha C Kakade, Anil K D'Cruz
Department of Head and Neck Surgery, Tata Memorial Hospital, Dr E. Borges Marg, Parel, Mumbai 400-012, India. firstname.lastname@example.org
The objective of the article is to study the prognostic indicators of loco-regional failure in patients with early stage cancers of the gingivobuccal complex (GBC) treated at a single institution. The study design is based on retrospective chart review. A review of 2,275 patients diagnosed with GBC was conducted from January 1997 to December 1999, wherein 207 patients who fulfilled our inclusion criteria were analyzed. Univariate analysis, multivariate analysis, and disease-free survival are reported. During a median follow-up of 2.85 years there were 85 (43%) loco-regional failures of which 64% could be salvaged. As much as 80% of all failures occurred within the first 24 months and the mean survival for patients with recurrences was 9.6 months. Two and five-year disease-free survival for the entire cohort was 65% and 52%, respectively. Nodal metastasis, soft tissue infiltration, and pathological bone involvement correlated with poor disease-free survival on multivariate analysis. Early stage tumors of the GBC as evaluated clinically are often upstaged pathologically due to a high rate of occult nodal metastasis and local failure as they tend to invade bone and infiltrate adjacent soft tissue. Consequently, we recommend aggressive surgical therapy as we would recommend for advanced stage cancers of the GBC which includes a wide three-dimensional resection to account for soft tissue and bony infiltrations and adjuvant therapy in the presence of adverse features since salvage rates for recurrent tumors are poor.
Age has no significant impact on overall survival and on treatment tolerability in relapsed stage IV cutaneous malignant melanoma patients receiving Cisplatin, Gemcitabine, and Treosulfan.
Fachklinik Hornheide an der Westfälischen Wilhelms-Universität Münster, Dorbaumstr, Münster, Germany. email@example.com
OBJECTIVES We compared the efficacy and tolerability of cisplatin, gemcitabine, and treosulfan (CGT) therapy in younger patients (age,<60 years) and in elderly patients (age, ≥60 years) with pretreated relapsed American Joint Committee on Cancer stage IV cutaneous malignant melanoma. PATIENTS AND METHODS A total of 91 patients at the age of 18 to 80 years, in relapse after first-, second-, or third-line therapy received 40 mg/m intravenous (i.v.) cisplatin, 1000 mg/m i.v. gemcitabine, and 2500 mg/m i.v. treosulfan on days 1 and 8. CGT-therapy was repeated every 5 weeks until progression of disease occurred. RESULTS Younger (n = 49) and elderly (n = 42) patients showed a significant difference in disease stabilization in 25% versus 7%(P ≤ 0.05), as opposed to 69% versus 91% patients exhibiting disease progression. In contrast, the overall median survival probability was not significantly different (P = 0.8153). Neither treatment-related toxicity nor toxicity-associated dose reduction showed substantial differences. CONCLUSIONS Our results demonstrated that CGT therapy could be safely administered to a patient up to age 80 years.
Jimmy J Caudell, Ruby F Meredith, Sharon A Spencer, Kimberley S Keene, M Christian Dobelbower, James A Bonner
Department of Radiation Oncology, University of Alabama-Birmingham, Birmingham, AL 35249, USA.
PURPOSE To determine whether the method or extent of construction of the high-dose clinical target volume (CTV) and high-dose planning target volume (PTV) in intensity-modulated radiation therapy (IMRT) for head-and-neck cancer are associated with an increased risk of locoregional failure. MATERIALS AND METHODS Patients with nasopharyngeal, oropharyngeal, oral cavity, hypopharyngeal, or laryngeal squamous cell carcinomas treated definitively with IMRT were included. All patients without local relapse had a minimum follow-up of 12 months. Median follow-up for all patients was 24 months. Treatment plans of 85 available patients were reviewed, and the gross tumor volume (GTV) to PTV expansion method was estimated. RESULTS The GTVs were expanded volumetrically in 71 of 85 patients, by a median of 15 mm (range, 4-25 mm). An anatomic component to the expansion of GTV was used in 14 of 85 patients. Eighteen patients failed locoregionally, for an actuarial locoregional control rate of 77.2% at 2 years. There was no significant difference in locoregional control between patients with GTVs expanded volumetrically vs. those with a component of anatomic expansion. In patients with GTVs expanded volumetrically, no increase in risk of local failure was seen in patients with a total GTV expansion of < or =15 mm. CONCLUSION In this retrospective study, there was not an increased risk of local failure using smaller margins or expanding GTVs volumetrically when treating head-and-neck cancer patients definitively with IMRT.