[Extended reversible global left ventricular contraction dysfunction with symptomless coronary system as effect of cytostatic therapy with 5-fluorouracil]

CASE REPORT

We report on a young female patient suffering from anal-cancer who received simultaneous radiochemotherapy and developed a "hibernating myocardium" during continuous infusion of 5-FU.

CONCLUSION

In literature the incidence of cardiac complications caused by 5-FU-therapy is found to be between 1% and 10%. Patients with coronary heart disease have a four-fold higher risk. Possible pathogenic mechanisms are spasm of coronary artery, direct cardiotoxicity, immunological reactions and disturbance of the coagulation system.

[Local therapy of Ewing sarcoma: radiotherapy aspects]

In CESS 86, radiotherapy and surgery as local treatment modalities yielded the same survival rates. Irradiated patients developed more local recurrences as compared to surgically treated patients (14% versus 4%), but less systemic metastases (16% versus 28%). The local recurrence rate after definitive radiotherapy dropped from 50% in CESS 81 to 14% in CESS 86. This was probably caused by an earlier start of radiotherapy (in week 10 in CESS 86 as compared to week 19 in CESS 81) and the high quality of radiation therapy in CESS 86 due to central treatment planning (only 2% protocol violations). Patients with local recurrences showed no differences in the distribution of major prognostic parameters (tumor volume, response to chemotherapy) as compared to patients with local control of disease. As a consequence of these results the concept of early irradiation with subsequent "consolidant" surgery for high-risk patients has been established.

[The adjuvant therapy of rectal carcinoma: its current status]

BACKGROUND

Adjuvant therapy of rectal cancer has been investigated in randomized trials during the past 20 years. The actual data allow to draw some principle conclusions.

RESULTS

Adequate surgical treatment is the basis for any adjuvant therapy. However, even in case of optimal surgery local recurrence rates of 20 to 30% are to be expected for stage II/III patients with 5-year survival figures in the range of 40 to 60%. In some series, e.g. the results of the Surgical Department of the University of Erlangen, a significant correlation between local control and survival exists. Postoperative radiotherapy decreases the risk of local recurrence but has--as postoperative chemotherapy--only marginal impact on survival. Combined adjuvant treatment (radiotherapy plus 5-FU-chemotherapy) has significantly increased the 5-year survival figures by 10 to 15% in 2 randomized trials and is considered as standard adjuvant treatment. From a radio-oncological point of view, most studies may be criticized at least in part because of low pre-operative doses, inadequate technique without individual treatment planning and shielding, unfavourable fractionation, or dose reductions of radiotherapy in case of chemotherapy. Further improvement of local efficacy of radiotherapy and reduction of therapy-related toxicity seems therefore possible. Innovative approaches in radiation oncology mainly include pre-operative strategies.

CONCLUSIONS

Postoperative radiochemotherapy (locoregional irradiation with 50 Gy, small volume boost, 6 courses with 5-FU) is recommended as standard adjuvant treatment outside clinical trials for stage II/III patients after curative surgery. Prospective studies should mainly focus on neoadjuvant treatment concepts.

[Radiotherapy of esthesioneuroblastoma]

AIM

To evaluate the radiocurability of esthesioneuroblastoma, we have retrospectively analyzed the results of radiation therapy in this tumor in our clinic.

PATIENTS AND METHODS

From 1985 through 1990, twelve patients with esthesioneuroblastoma have been treated at the Department of Radiotherapy at the University of Erlangen. Two had Kadish stage A, one stage B, and nine stage C. There were seven males and five females with a mean age of 43 years. Eleven patients had combined transcranial-transbasal surgery prior to radiotherapy (five R0-, four R1-, and two patients R2-resections) and one received radiotherapy only. The dose was 12 to 60 Gy (mean 54 Gy) in 1.8 Gy to 2 Gy per fraction.

RESULTS

8/12 patients (67%) were locally controlled. One had progressive disease during radiotherapy after partial resection and died. Three had local recurrences, one in-field and two marginal. One patient with a local recurrence developed cervical lymph node metastases, and one locally controlled patient developed bone metastases but is alive eight years after chemotherapy plus radiotherapy for metastatic disease. The five-year-overall and recurrence-free survival was 72% and 55%, respectively.

CONCLUSIONS

Sophisticated surgery plus radiotherapy may cure a reasonable number of patients with esthesioneuroblastoma.

[Therapy of Ewing's sarcoma]

Therapy of Ewing's sarcoma requires a qualified clinical, radiological, and pathohistological diagnosis and, in particular, an optimal therapy by an experienced team of oncological specialists. Important prognostic factors are the presence of hematogenous metastases at diagnosis, the initial tumor volume, the response to chemotherapy, and adequate local therapy. Presently, cure rates of more than 60% can be achieved for localized Ewing's sarcoma by combination of local therapy and chemotherapy. The four-drug combination VACA (vincristine, actinomycin D, cyclophosphamide, adriamycin) can be considered as cytostatic gold standard. More aggressive regimens (VAIA, EVAIA, autologous bone marrow transplant) may be beneficial in subgroups and are under investigation. Concerning local therapy adequate radiotherapy plays a major role and achieves the same survival rates as radical surgery, comparable patient selection provided. Several factors have impact on radiotherapeutic results, especially total dose (45 Gy large volume, 55 Gy to the primary tumor), target volume (safety margin at least 2 cm according to the pretreatment volume, at least 5 cm in proximal and distal extension of long bones), timing of radiotherapy (as early as possible) and quality of treatment. Radiotherapy as sole local treatment is indicated in inoperable lesions (spine, sacrum, skull) and in small, good-responding tumors. High-risk patients should receive combined radiotherapeutic-surgical treatment, preferably as pre-operative irradiation. The value of hyperfractionation is not yet proven despite theoretical advantages.

Lung irradiation for Ewing's sarcoma with pulmonary metastases at diagnosis: results of the CESS-studies

BACKGROUND

In the German CESS-studies, Ewing's sarcoma patients with pulmonary metastases at diagnosis were considered as candidates for additional bilateral lung irradiation. We have retrospectively analyzed the impact of radiotherapy on survival.

MATERIAL AND METHODS

Out of 42 patients presenting with pulmonary metastases of Ewing's sarcoma between 1981 and June 1992, 30 were evaluable. One patient died of progressive disease prior to lung irradiation. The other patients had a complete radiographic remission either after chemotherapy (n = 25) or chemotherapy plus resection of lung metastases (n = 4). 22 patients received bilateral lung irradiation with doses of 12 to 21 Gy (once daily 1.5 Gy or twice daily 1.25 Gy), six had no further treatment and one had bone marrow transplantation for consolidation.

RESULTS

Ten patients are in complete remission, nine of them had received lung irradiation and one had a complete resection of three lung metastases. Two patients are alive with disease, two have died from treatment-related complications and 16 have died from systemic disease with or without local relapse. NED-patients had received significant higher lung doses than relapsed patients p = 0.028. Moreover, a dose-response relationship was detectable: 1/6 patients without lung irradiation vs. 4/10 with 12 to 16 Gy vs. 5/6 with 18 to 21 Gy lung irradiation were in remission.

CONCLUSION

In this retrospective analysis, lung irradiation was beneficial in terms of improved survival of patients with pulmonary metastases of Ewing's sarcoma. We actually recommend lung irradiation with 18 (to 20) Gy for pulmonary metastases of Ewing's sarcoma.

[Radiation-induced myelitis following accelerated radiotherapy]

We report a case of suspected radiation-induced myelitis after twice-daily irradiation with a cord dose of 45.8 Gy. The 48-year old patient had been irradiated with two daily fractions of 1.8 Gy up to 70.2 Gy for oropharyngeal cancer T4 N2 G3 M0 and achieved a complete remission. The spinal cord received 42 Gy by open fields plus 3.8 Gy scatter irradiation after field reduction. Six months after radiotherapy clinical signs of tetraparesis occurred with two lesions in the cervical cord on MR-images. A complete neurological diagnostic procedure revealed no other causes than suspected radiation damage. This is the only case of radiation myelitis among 90 patients treated twice daily and over 2000 patients irradiated with conventional fractionation in the same technique and doses.

[Results of treatment of primary exclusively pulmonary metastatic Ewing sarcoma. A retrospective analysis of 41 patients]

41 patients presenting with primary metastatic Ewing's sarcoma or malignant peripheral neuroectodermal tumor (PNET) with initial metastases restricted to the lungs and/or pleural space were analysed with respect to clinical manifestation and treatment results retrospectively. All patients were treated according to the protocols CESS 81 and CESS 86 of the German Society of Pediatric Oncology and Hematology (GPOH). The time since diagnosis ranges from 19 to 137 months, with a median of 72 months. Median relapse-free survival time was 21.8 months. 18 patients were female, 23 were male. The majority of primary tumors exceeded 100 ml of volume. Preferred sites were the pelvis with 16 cases, the limbs with 14 cases and the chest wall with 6 cases. The histological specification of the tumor was Ewing's sarcoma in 22 and PNET in 11 patients, in 8 cases no specific distinction was given. As to local therapy of the primary tumor, 12 patients underwent radiotherapy, 11 surgery, and 18 a combination of both. Patients were allocated to one of these three options on an individual basis. Cytostatic drug treatment was given according to the GPOH-CESS 81 and CESS 86 protocols. As calculated by means of the Kaplan-Meier analysis, relapse-free survival was 30% ten years after diagnosis. Surgery or pulmonary irradiation of 12-20 Gy was applied to lung metastases. 12 of 27 patients are in continuous complete remission following this therapeutic approach.

[Simultaneous radiochemotherapy]

Simultaneous radiochemotherapy (RCT) means the simultaneous application of radiotherapy and chemotherapy. The major objective of this approach is the improvement of local control. On the cellular level, three types of interactions may be distinguished: additivity, synergism, and sensibilization. The main type of interaction seems to be a simple additive effect. The clinical effect of a simultaneous chemotherapy depends mainly on the cytotoxic action of the drug itself and not on radiosensibilization. Therefore, effective chemotherapeutic drugs are to be delivered in cytotoxic dosages in RCT protocols. Compromises in radiotherapy as the main modality should be avoided. Recent clinical data have shown that simultaneous radiochemotherapy may yield high remission rates in a number of tumor entities (e. g. anal cancer, bladder cancer, head and neck cancer). This seems to improve local control as compared to radiotherapy alone. In some tumors (e. g. head and neck, esophagus), survival may be improved also. However, several questions require future detailed clinical trials. These questions include the value of simultaneous radiochemotherapy compared to optimal fractionation schemes, the clear definition of subgroups of patients with benefit by radiochemotherapy and the optimal dose intensity of cytotoxic drugs.

[Organ-preserving therapy in invasive bladder carcinoma]

With the aim of organ preservation, transurethral resection with subsequent radiotherapy (until 1985) or combined radio- and chemotherapy (since 1986) was undertaken as part of a prospective trial in 175 consecutive patients (137 men, 38 women; mean age 65 [31-90] years) with invasive bladder carcinoma, tumour stage T1-4 N0-3 M0. All patients had a transurethral resection, followed 2-6 weeks later by definitive radiotherapy at a dose of 50.4 Gy to the bladder in 28 fractions. 85 patients simultaneously with the radiotherapy received chemotherapy with cisplatin (25 mg/m2 daily) or carboplatin (65-75 mg/m2 daily) in the first and fifth weeks of radiotherapy. The 5-year survival rate for the whole group (including inoperable cases) was 50%. The survival rate as related to the T category was 53% for T1 (n = 26), 68% for T2 (n = 34), 45% for T3 (n = 94) and 22% for T4 (n = 17). 139 patients (79%) were left with a normally functioning bladder. Cystectomy was performed in 36 patients because of remaining tumour or recurrence after radiotherapy. Combined radio- and chemotherapy improved the histological remission rate, compared with an earlier control group with radiotherapy only, but it did not affect the survival rate. These data indicate that in advanced bladder carcinoma organ-preserving treatment with transurethral resection and definitive radiotherapy or combined radio- and chemotherapy can be successful.

Breast preservation versus mastectomy in early breast cancer--1991 update of the GBSG 1--protocol and prognostic factors. The German Breast Cancer Study Group

In 1983, the German Breast Cancer Study Group (GBSG), sponsored by the Federal Ministry of Research and Technology, started a prospective multicenter trial on the treatment of early breast cancer (pT1 pN0 M0). This was preceded by a three-year reviewing period because of some novelties of medical, juristical and ethical problems in the FRG. University and, in the majority, community hospitals participated, combining all together 69 different institutions. From 11/1983 to 12/1989, 1112 patients were recruited. From 1036 patients, 733 underwent breast preservation (71%) and 303 mastectomy (29%). The randomization rate was only 6%. In 268 patients (26%) the tumor size was less than or equal to 10 mm, in 765 patients (74%) 11 to 22 mm. In 129 cases, we subdivided the tumor grading II[3] into IIa and IIb. Moreover, the immunohistochemical detection of the transmembrane proteins EGFR, p-185 and p-148 by oncogene overexpression and c-myc oncogene were undertaken in 425 breast cancers. After tumorectomy (or wide excision) and a lower axillary dissection (at least eight lymph nodes) the breast was irradiated up to 50 Gy in 25 fractions. A boost of 12 Gy was given to the tumor bed. The medial located lymph nodes were also irradiated in case of medially or centrally tumors. Quality control was performed by pathological, radiotherapeutic and methodical reference centers. Significant correlations could be demonstrated between receptor status and tumor grading, patient age and grading, and tumor size and grading. The results emphasize the central role of tumor grading among the prognostic factors. Especially the differentiation of the Bloom and Richardson score II into IIa and IIb seems to play an important role. After a median follow-up of 41 months, the frequency of local recurrences (4.4%), regional recurrences (1%) and distant metastases (4.6%) was exactly the same in both treatment groups. In multivariate analysis, only tumor size and tumor grading had a significant impact on disease-free survival. 23 patients with tumor-involved margins had a higher recurrence rate (DFS 62% versus 85% after five years). Without any impact on DFS were the other conventionally evaluated prognostic factors: age, menopausal status, hormone receptor status, histological tumor type, tumor localisation, degree of differentiation, pleomorphism, mitotic index and degree of dissociation. Among the transmembrane proteins EGFR, p-185, p-148 and c-myc, only the impact of p-185 and EGRF positivity on DSF is significant.(ABSTRACT TRUNCATED AT 400 WORDS)

Therapy of small breast cancer: A prospective study on 1036 patients with special emphasis on prognostic factors

In 1983, The German Breast Cancer Study Group, sponsored by the Federal Ministry of Research and Technology, started a prospective multicenter trial on the treatment of early breast cancer pT1 pN0 M0. Treatment consisted of initial tumorectomy with microscopically free margins and lower axillary dissection. After conformation of a pT1 pN0-stage, additional treatment was either mastectomy or adjuvant radiotherapy (50 Gy in 25 fractions to the entire breast plus 12 Gy electron boost). In medially located tumors, the parasternal and supraclavicular area was also irradiated with 50 Gy. A randomization between both treatment modalities was initially planned but was not feasible and abandoned. Nearly all patients were treated according to their own choice. From November 1983 through December 1989, 1119 patients were recruited. Eighty-three were excluded from the protocol. Out of the remaining 1036 patients, 733 (71%) underwent breast preservation and 303 (29%) mastectomy. A detailed pathohistological examination of all tumorectomy specimens was performed in a pathologic reference center. Oncogen overexpression was evaluated by immunohistological detection of the transmembrane protein p-185 (corresponding to c-erb-B2) in 425 cases. After a median follow-up of 48 months, the frequency of local recurrences (4.7%), regional recurrences (1%), and distant metastases (5.4%) was the same in the breast preservation group and the mastectomy group. The 3-year disease-free survival was 90% after breast preservation and 88% after mastectomy (p = 0.21). In the breast preserving group, 24 patients with microscopically involved margins had a poorer disease-free survival than the study group (75% vs 90% after 3 years). The width of the margins had no impact on prognosis. Other prognostic factors in an univariate and multivariate analysis were tumor size and tumor grade. Age, menopausal status, hormone receptor status, histological tumor type, and treatment (mastectomy vs breast preservation) were not significant. P-185-expression was dependent on tumor grade and was the strongest prognostic factor in an univariate and multivariate analysis (p less than 0.001). The results emphasize the central role of tumor grade for prognosis and suggest the independent prognostic significance of the c-erb-B2 oncogen (corresponding to p-185) in pN0-patients.

[Radiotherapy in the interdisciplinary approach to the treatment of bladder carcinoma]

Bladder cancer accounts for approximately 3% of all malignancies. About 70% of bladder cancers are superficial tumors (Ta, Tis, T1), the remaining 30% are muscle-invasive (T2-4). Important prognostic factors include TNM-stage, histologic grade, multifocality, associated Tis, and residual tumor after TUR. Superficial cancers are managed by TUR and, if necessary, intravesical chemotherapy, and bladder preservation is possible. In case of T1G3-cancers, we favour TUR plus irradiation with a moderate dose instead of cystectomy. Even advanced bladder cancers may be treated by an organ sparing approach. TUR plus radiotherapy or radiochemotherapy offer comparable survival figures and local control rates as compared to radical cystectomy. The 5-year survival rates are 60-70% for T1-2, 40% for T3, and 15% for T4-tumors. About 70% of long-term survivors maintain a functioning bladder. Radiochemotherapy (RCT) with platin compounds is equally effective but less toxic as compared to multi-agent chemotherapy or intraarterial administrations. We do not recommend preoperative radiotherapy or RCT with planned cystectomy because of the definitive organ loss. Optimal treatment results are achieved by complete TUR prior to irradiation. Persistent or recurrent tumor after radiotherapy requires salvage cystectomy. Intravesical recurrences in the spared bladder have a good prognosis. Adjuvant chemotherapy of bladder cancer is not established. Neoadjuvant chemotherapy may result in 20-30% complete remissions, but these figures are lower than those after radiotherapy or radiochemotherapy. Nevertheless, adjuvant treatment protocols are necessary because of the fact that even sophisticated local treatment with increased local control has not yet improved the overall survival rates.