Results of mastectomy and postoperative irradiation in the management of locoregionally advanced carcinoma of the breast

Between 1955 and 1984, 376 patients with locoregionally advanced breast carcinoma were treated at The University of Texas M. D. Anderson Cancer Center with mastectomy and irradiation and without adjuvant chemotherapy. Patients with inflammatory carcinoma or synchronous bilateral primary tumors were excluded. There were 202 patients with Stage IIIA disease and 174 patients with Stage IIIB disease (AJC Staging--1983). In 124 patients the surgical management was confined to the breast only--total mastectomy (BR) and in 252 dissection of the axilla was performed--extended total, modified radical, or classic radical mastectomy (BR + AX). All patients had postoperative irradiation. The follow-up period ranged between 8 and 34 years. At 10 years, the actuarial disease-specific, relapse-free survival (DSRFS) rate for the entire group was 40%, and the actuarial locoregional control rate was 82%. For patients with Stage IIIA disease the DSRFS was 48% and locoregional control rate was 88%. For those with Stage IIIB disease, the figures were 30% and 74%, respectively. Most of the failures occurred within 5 years of the mastectomy and essentially all occurred within 10 years. When analyzed by type of surgery, both the locoregional control and DSRFS rates were improved by the axillary dissection, the difference being largely caused by fewer axillary node recurrences after dissection of both the breast and axilla than after removal of the breast alone. In the 252 patients in whom the axilla was assessed, the number of positive nodes was a powerful predictor of both locoregional control and survival. The DSRFS rates at 10 years for patients with 0, 1-3, and greater than or equal to 4 positive nodes were 63%, 48%, and 30%, respectively. The actuarial locoregional control rates at 10 years exceeded 95% for patients with 0-3 positive nodes and 75% for those with greater than or equal to 4 nodes. These results show that locoregionally advanced breast cancer is not a uniformly fatal disease when treated without chemotherapy and provide a baseline upon which to assess the value of adjuvant systemic therapy for this stage of disease.

Maxillary sinus carcinomas: natural history and results of postoperative radiotherapy

Between 1969 and 1985, 73 patients with maxillary sinus cancers underwent surgical excision and postoperative radiotherapy. The clinical stage distribution by the AJC system was 3T1, 16T2, 32T3, and 22T4. Six patients had palpable lymphadenopathy at diagnosis. Surgery for the primary tumor consisted of partial or radical maxillectomy, and if disease stage indicated it, ipsilateral orbital exenteration. This was followed by radiation treatment delivered through a wedge-pair or three-field technique. All but three patients received 50-60 Gy in 2 Gy fractions to an isodose line defining the target volume. Elective neck irradiation was not routinely given. Clinically involved nodes were treated with definitive radiotherapy (five patients) or combined treatment (one patient). Forty-five patients had no evidence of disease at the last follow-up. The 5-year relapse-free survival for the whole group was 51% The overall local control rate was 78%. Patients with larger tumors, particularly if they also had histological signs of nerve invasion, had a higher recurrence rate than others. The overall nodal recurrence rate without elective neck treatment was 38% for squamous and undifferentiated carcinoma, and only 5% for adenoid cystic carcinomas. Therefore, our current recommendation is to deliver elective nodal irradiation routinely to patients with squamous or undifferentiated carcinoma, except for those who have T1 lesions. Treatment complications were vision impairment, brain and bone necrosis, trismus, hearing loss, and pituitary insufficiency. The incidence of major side effects was determined by disease extent and treatment technique. Many technical refinements were introduced in order to limit the dose to normal tissues in an attempt to reduce the complication rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Early stage I adenocarcinoma of the uterine cervix: treatment results in patients with tumors less than or equal to 4 cm in diameter

Between 1965 and 1985, 160 patients had initial treatment at the M. D. Anderson Cancer Center for Stage I adenocarcinoma of the uterine cervix less than or equal to 4 cm in diameter. Of these patients, 84 were treated with radiation therapy (RT) alone, 20 were treated with external and intracavitary radiation followed by total hysterectomy (R + S), and 56 were treated with radical hysterectomy (RH). Survival rate was strongly correlated with tumor volume (P = 0.0008), lymphangiogram findings (P = 0.01), and tumor grade (P = 0.0018). Patients with a normal-appearing cervix or a small visible or palpable tumor that did not expand the cervix more than 3 cm had survival and pelvic-control rates of more than 90% after treatment with RH or RT. However, after 5 years, 45% of patients treated with RH for tumors 3-4 cm in diameter had disease recurrence in the pelvis, compared with 11% of patients treated with either RT or R + S (P = 0.025). For patients treated with RH, recurrence was also strongly correlated with findings of lymph/vascular space invasion (P = 0.0004) and poorly differentiated tumor (P = 0.018). Major complication rates were comparable for the three treatment groups. The high rate of pelvic recurrence following treatment with radical hysterectomy alone for patients with tumors greater than 3 cm in diameter, particularly in the presence of lymph/vascular space invasion, poorly differentiated features, and/or positive nodes, should be considered in planning the primary management of patients with Stage I adenocarcinoma of the cervix.

Salvage treatment for loco-regional recurrence following breast conservation therapy for early breast cancer

We reviewed the management of 55 cases of loco-regional recurrence after limited surgery and irradiation for breast cancer. Forty-three patients had disease localized to the breast, with axillary involvement in seven. Four had axillary relapse without tumor recurrence in the breast. Eight had breast recurrence extending to involve the chest wall. Mastectomy was used successfully for 41 first recurrences, and seven were controlled by wide excision; 21 of 48 patients also received chemotherapy and/or hormonal manipulation. Diffuse soft-tissue tumor required systemic therapy first, followed by wide excision when possible. Eighty-nine percent of first recurrences were controlled but disease recurred again in eight patients. Overall, 80% of cases were free of loco-regional disease at a median follow-up of 27 months. Reconstructive surgery was valuable for wound closure after wide resections, and for cosmetic procedures. Despite the previous irradiation, surgery complications were acceptable.

Radiation therapy following resection of non-small cell bronchogenic carcinoma

Between 1970 and 1982, 102 patients received postoperative radiotherapy after attempted curative resection of bronchogenic carcinoma at The University of Texas M. D. Anderson Cancer Center. Surviving patients had a minimum follow-up of 3 years. Eight patients had pathological Stage I disease, 29 Stage II, and 65 Stage III. The 5-year actuarial survivals for patients with stages I, II, and III disease were 83%, 55%, and 38%, respectively (p = .04). Corresponding values for patients with N0, N1, and N2 disease were 74%, 56%, and 28% (p = .01). No significant differences in survival were seen based on T stage or tumor histology. Nine patients had gross residual disease following surgery, and 19 had microscopic residual disease. The 5-year actuarial survival was 78% for 12 patients without nodal disease who had known gross (4 patients) or microscopic (8 patients) residual tumor following attempted curative resection. The pathologic status of the hilar and mediastinal lymph nodes was the most significant factor affecting the frequency of metastatic relapse, with 19% of patients with N0, 33% of those with N1, and 69% of those with N2 disease developing distant disease. The low overall rate of recurrence intrathoracically (16%) confirms that postoperative radiotherapy is effective in preventing local relapse even in patients with proven nodal involvement. The impact of adjuvant radiation therapy on survival cannot be determined from these data, and further data are needed, preferably from well designed prospective studies.

The role of serum prostatic acid phosphatase in the management of adenocarcinoma of the prostate with radiotherapy

Between 1974 and 1983, 472 patients with clinically-staged adenocarcinoma of the prostate treated by radiotherapy had baseline and follow-up prostatic acid phosphatase (SPAP) measurements by the enzymatic Roy method. The mean pretreatment SPAP was higher in Stage C (0.65 mIU/ml) than in combined Stages A2/B (0.43 mIU/ml), (p less than 0.05). Likewise, the incidence of elevated SPAP (greater than 0.8 mIU/ml) was also higher in Stage C (12%) than in Stages A2/B (3%), (p less than 0.01). Only 3 of 113 patients in Stages A2/B had an elevated SPAP and all three remain disease-free. In Stage C elevated SPAP was an adverse prognostic factor, and patients with a normal SPAP fared worse if their value was in the upper half of normal (greater than 0.4 mIU/ml) rather than in the lower half (less than or equal to 0.4 mIU/ml). However, in Stage C, tumor grade was found to correlate with initial SPAP, so that the higher the grade, the higher was the mean SPAP and the greater was the incidence of elevated SPAP. When stratified for grade, the prognostic significance of low-normal versus high-normal SPAP in Stage C was lost. An elevated SPAP was, however, an independent adverse prognostic factor for patients with intermediate and high grade tumors. Following radiotherapy, mean SPAP values fell significantly within 1-3 months. For patients with initially normal SPAP, this fall was of no prognostic significance. In 80% of the patients with baseline elevation of SPAP, the values normalized following treatment and the relapse rate in these patients was 51%, which was still higher than the relapse rate of patients with initially normal SPAP (33%) (p less than 0.05) but was lower than the 89% relapse rate in patients whose postradiation SPAP did not normalize (p less than 0.05). Pretreatment SPAP was of independent prognostic significance for only 6% of the study population and therefore has quite limited usefulness in the management of this disease. SPAP decreases following radiotherapy, but this is of prognostic significance only for the small group of patients with elevated pretreatment values.

Nasopharyngeal carcinoma in the young: a combined M.D. Anderson and Stanford experience

From 1956 to 1988, 57 children and young adults (age 4-21 years) with a diagnosis of nasopharyngeal carcinoma were treated at The University of Texas M.D. Anderson Cancer Center (42 patients) and Stanford University Medical Center (15 patients). The male to female ratio was 2:1. Forty-three patients had lymphoepithelioma, seven had undifferentiated neoplasms, and seven had squamous cell carcinoma. Two patients had Stage III disease and the remainder had Stage IV disease at the time of presentation. All patients were treated with primary radiotherapy, and 14 patients also had chemotherapy with combinations of the following drugs: dactinomycin, doxorubicin, bleomycin, cisplatin, cyclophosphamide, fluorouracil, methotrexate, and vincristine. Twenty-six patients are alive 6 to 178 months from the first day of treatment (median 93 months). The 5- and 10-year actuarial survival rates are 51% and 36%, respectively, and the corresponding disease specific survival rates were 51% and 51%. There were no recurrences after 42 months. The patterns of failure were as follows: distant metastasis only, 21 patients; locoregional metastasis only, 1; both, 5. Distant metastases most commonly occurred in bones, lungs, liver, and mediastinal lymph nodes. Chronic treatment-related morbidity was encountered in a significant number of long term survivors. Trends in the data not reaching statistical significance suggest a more favorable prognosis for a) females, b) patients less than or equal to 15 years of age, c) lymphoepithelioma or undifferentiated histologies, d) stages T3-4 NO-1 vs T1-2 N2-3 vs T3-4 N2-3, e) primary tumor dose greater than or equal to 65 Gy and f) patients who received chemotherapy.

Survival following locoregional recurrence after breast conservation therapy for cancer

We postulated that locoregional recurrence after limited surgery and radiotherapy for breast cancer might be associated with an additional survival hazard, similar to that of a second primary tumor with the same extent of local and regional disease. Using this hypothesis we examined the likely resultant effect on survival. Our calculations indicated that no statistically significant survival deficit due to such recurrence would be detectable until a randomized controlled trial comparing breast conservation with mastectomy had monitored more than 10,000 patients for more than 10 years. A simple mathematical model predicted 5-year survival rates in a cohort of patients treated with breast conservation of 75%, compared to 83% in those without locoregional recurrence. From the date of locoregional recurrence, a 61% 5-year survival rate was predicted, compared to 83% if no hazard was associated with locoregional recurrence. These predictions were compared with the actuarial survival rates of 499 patients with unilateral breast cancer, 49 of whom had developed locoregional recurrence. From the date of initial treatment, the 5-year survival rate of those whose disease recurred was 79%, compared to 88% for those without locoregional recurrence (p = 0.19). The actuarial 5-year survival rate from the date of locoregional recurrence was 63%. The similarity between the patient data and the predictions of the mathematical model indicates that locoregional failure after breast conservation therapy may result in reduced survival. The lack of a significant survival deficit in our cohort or in controlled trials comparing breast conservation therapy with mastectomy is compatible to the small size of the overall effect.

Desmoid tumors: a 20-year radiotherapy experience

From 1964 through 1984, 45 patients were referred for radiation therapy for desmoid tumor. Fourteen patients had inoperable lesions, or gross residual disease after incomplete resection. Thirty-one patients received postoperative XRT for positive margins or concern about the adequacy of the margin. The minimum follow-up was 2 years, maximum 22 years, median 7.6 years. No patient was lost to follow-up. The primary site was head and neck in 5, upper extremity in 10, chest wall and back in 8, abdomen 2, pelvis 4, and lower extremity 16. All patients were treated with megavoltage radiation therapy using shrinking field techniques. Large fields received a median dose of 50 Gy in 25 fractions. Boost fields were used in the majority of patients to deliver an additional dose of 7 to 27 Gy. The range of total doses was 50 to 76.2 Gy. Three patients received a boost with neutrons. Analysis of patients with inoperable or gross residual showed tumor control in 10 of 14 with a median follow-up of 9.4 years. Resolution of gross disease occurred at a range of 1/2 to 64.3 months with a median of 9 months. There was no evidence of a higher probability of ultimate control at higher doses. Tumor control was equal for men and women. The ten patients with local control had doses from 50 to 76.2 Gy whereas the four patients with in field failures had tumor doses of 57 to 66.4 Gy. There was no difference in median dose for patients with local control (60.3 Gy) versus those with tumor recurrence (60 Gy). For subclinical disease, 31 patients receiving postoperative or preoperative XRT had a 77 percent probability of local control in spite of the history of multiple tumor recurrences; local control was achieved in 8 of 9 with negative or uncertain margins and 16 of 22 with positive margins. An analysis of local control as a function of the number of operations revealed that patients referred for adjuvant radiotherapy with no more than two operative procedures had an 88 percent probability of local control, versus 66 percent for more than two operative procedures. All grade 3 complications (defined as requiring surgical intervention or prolonged hospitalization) occurred with doses above 60 Gy. Management of recurrences was successful in 8 of the 11 patients and no patient has died of tumor.(ABSTRACT TRUNCATED AT 400 WORDS)

T2 glottic cancer. Recurrence, salvage, and survival after definitive radiotherapy

The records of all patients with T2, NO squamous cell carcinoma of the true vocal cords treated with definitive radiotherapy at The University of Texas M. D. Anderson Cancer Center between 1970 and 1985 were analyzed to investigate treatment outcome, prognostic factors associated with tumor recurrence, and the potential impact of improved initial treatment on patient survival. There were 114 patients (male to female ratio, 13:1) with a median age of 62 years at presentation. All were treated with external beam irradiation to a modal dose of 70 Gy in 35 fractions over 7 weeks. The median field size was 25 cm2 and no elective treatment to the neck was routinely given. The crude recurrence rate after definitive radiotherapy was 32%. Of the 37 local regional failures, 32 were in the larynx only, 3 in the neck, and 2 in both the larynx and the neck. All patients who had recurrence after radiotherapy underwent salvage procedures, which increased the ultimate control rate above the clavicles to 94%. Overall and disease-specific survival rates at 5 years were 69% and 92%, respectively. Fifty patients died: 7 of laryngeal cancer, 2 of complications of salvage surgery, 13 of unrelated second cancers, and 28 of other intercurrent disease. The prospects for improved survival through more effective initial treatment of this stage of glottic cancer are therefore very limited. Significant complications of radiotherapy occurred in only 4 patients (3.5%), and overall, 74% of patients retained a functional larynx. Analysis of a wide variety of patient-, tumor-, and treatment-related variables failed to identify any statistically significant prognostic factors.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary radiotherapy in the treatment of stage I and II oral tongue cancers: importance of the proportion of therapy delivered with interstitial therapy

From January 1963 through December 1979, 103 patients with Stage T1N0 and T2N0 squamous cell carcinomas of the oral tongue were treated with definitive radiotherapy. The primary was Stage T1 in 18 patients and T2 in 85 patients. Therapy to the primary consisted of interstitial therapy only in 18 patients, 16-37 Gy in 2.4-4.0 Gy fractions followed by interstitial therapy to doses of 38-55 Gy in 31 patients, external therapy of 40-50 Gy with interstitial therapy of 20-40 Gy in 46 patients, and external beam only to doses of 45-82 Gy in 8 patients. Follow-up ranged from 2 to 290 months (median 159 months). Five of the 8 patients treated with external therapy alone and 6 of the 18 patients treated with interstitial therapy failed at the primary site. In those patients treated with a combination of external and interstitial therapy the 2-year local control rate was 92% for patients treated with external therapy to doses of less than 40 Gy combined with a moderately high dose of brachytherapy, compared with 65% for patients who received external therapy to doses of greater than or equal to 40 Gy with lower brachytherapy doses (p = .01). Conversely the risk of failure in the neck was directly related to the dose delivered by external beam therapy. In field recurrence occurred in 44% of patients receiving no therapy to the neck. 27% in those receiving less than 40 Gy, and 11% in those patients with neck treatment to greater than or equal to 40 Gy. Eleven of 87 (13%) of patients who were at risk for complications for greater than or equal to 24 months developed severe complications; severe complications were more likely to occur in the group who received most of their therapy with external beam irradiation. These data show that a high dose of interstitial therapy is necessary to secure optimum local control of early primary tongue cancer. Because of the high frequency of moderate to severe late complications in this series we have adopted a policy of initial surgery for most oral tongue cancers with postoperative radiotherapy if indicated by pathological features predictive of a high rate of local-regional failure.

Adenocarcinoma of the uterine cervix. Prognosis and patterns of failure in 367 cases

Between 1965 and 1985, 367 patients received initial treatment for adenocarcinoma of the uterine cervix at the M. D. Anderson Cancer Center (MDACC). Of the 334 patients treated with curative intent, 223 had International Federation of Gynecology and Obstetrics (FIGO) Stage I, 60 had Stage II, and 51 had Stage III/IV disease. The 5-year and 10-year relapse-free survival (RFS) rates for all patients treated for Stage I disease were 73% and 70%, respectively. RFS was strongly correlated with initial bulk of disease (P = 0.002), although locoregional control (LRC) was good in all groups: 91 patients with a normal-sized cervix (tumor less than 3 cm) had a 5-year RFS rate of 88% and an actuarial LRC rate of 94%; 102 patients with lesions 3 to 5.9 cm in diameter had an RFS rate of 64% and an LRC rate of 82%; and 22 patients with bulky lesions greater than 6 cm in diameter had a comparable LRC rate of 81%, but an RFS rate of only 45%. Decreased RFS also was strongly correlated with positive lymphangiogram (LAG) results (P = 0.02) and poorly differentiated lesions (P = 0.0014). When initial primary tumor size was taken into account, there was no significant difference in RFS or LRC between patients treated with radiation (RT) alone or RT plus extrafascial hysterectomy (R + S). The 5-year and 10-year RFS rates of 60 patients who received curative therapy for Stage II disease were 32% and 25%, respectively, with an LRC rate of 62% at 5 years. Patients with bulky Stage II disease did particularly poorly, with a 5-year RFS rate of 15%. Decreased RFS was correlated with positive LAG results and poorly differentiated tumors. Most Stage II patients whose disease relapsed died with distant metastases (73%). Forty-eight patients with Stage III/IV disease treated with curative intent had a 5-year survival rate of 31% and a 5-year pelvic disease control rate of 52%. In summary, patients with small volume Stage IB lesions have excellent LRC and survival with RT alone. RT achieves good LRC of bulkier Stage I lesions, but survival decreases with increasing primary tumor size. R + S holds no apparent advantage over RT alone. Patients with more advanced disease have a high rate of relapse with frequent distant metastasis. In particular, the survival of patients with FIGO Stage II disease is much lower than what we have observed after treatment of comparable stage squamous carcinoma.(ABSTRACT TRUNCATED AT 400 WORDS)

The role of limited surgery with irradiation in primary treatment of ductal in situ breast cancer

The results of management of ductal carcinoma in situ with limited surgery and radiotherapy are presented at a median follow-up of 92 months. In 44 treated breasts the actuarial 10-year loco-regional control rate was 91%, four patients having recurred. Each loco-regional failure was due to invasive carcinoma and three of the affected patients have developed metastases. No patient developed metastases without previous clinically-evident invasive loco-regional disease. The 10-year disease-specific survival rate was 96%. Previous publications have shown that the 25% or greater risk of local failure after limited excision of ductal carcinoma in situ can be reduced by irradiation of the breast. Our results demonstrate that good loco-regional control is maintained in the longer term.

Predicting the rate and extent of locoregional failure after breast conservation therapy for early breast cancer

Five hundred thirty-six cases of early breast cancer (T0 to T2, N0 to N1) treated with breast conservation therapy were monitored for a median interval of 64 months. Fifty-five locoregional failures occurred after a median interval of 40 months; the actuarial failure rate was 9% at 5 years and 19% at 10 years. Factors predicting locoregional failure were sought. Young patients had a higher risk of failure than older patients, although their actuarial survival rates were not different. Locoregional failure was defined as advanced if tumor involved skin or was fixed to the chest wall, the diameter was greater than 5 cm, or unresectable nodes were present. There was a significantly higher incidence of advanced recurrence with higher initial tumor stage. Overall, the 5-year survival rate after treatment of locoregional recurrence was 63%. Advanced locoregional failure, however, resulted in a median survival time of 37 months. Further study is required to explain the increased failure rate in younger women. Advanced locoregional failure rarely occurred after treatment of Stage 0 or Stage I tumors, supporting the selection of patients with early disease for breast conservation therapy.

Hyperfractionated radiotherapy in the treatment of squamous cell carcinomas of the supraglottic larynx

From January 1984 through December 1987, 41 patients with squamous cell carcinomas of the supraglottic larynx were treated with hyperfractionated radiotherapy at The University of Texas M. D. Anderson Cancer Center. Two patients had T1 primary tumors, 23 had T2, 15 had T3, and 1 had T4; 29 patients had no clinical evidence of nodal disease in the neck, 4 had N1, 5 had N2, and 3 had N3. Radiotherapy was delivered in 120 cGy fractions twice per day, with at least 4 hr between treatments. Total doses ranged from 7200 to 7900 cGy (median, 7680 cGy). Three patients had planned neck dissections before or after radiotherapy, and three patients with fixed vocal cord lesions were treated with preradiation chemotherapy. At the time of analysis, median follow-up was 22 months. Four patients have had failures at the primary tumor site. There has been one recurrence in the neck in a patient who also had a recurrence at the primary site. Three of the four patients with recurrences have been successfully treated with salvage surgery. Exclusive of surgical salvage, the actuarial disease-free local control rates above the clavicles in the 38 patients with T2 and T3 cancers were 96% at 1 year and 87% at 2 years. In comparison, the rates were 82% and 76% for a group of 98 patients with T2 and T3 lesions treated at this institution from 1970 to 1981 with 6500-7000 cGy given in 200 cGy fraction per day. As predicted, acute reactions were more severe but late complications were not increased in patients who received hyperfractionated radiotherapy compared with those treated by conventionally fractionated therapy. Only two patients have developed severe late complications one of whom required laryngectomy. Hyperfractionated radiotherapy appears to provide improved local control with a similar incidence of late complications when compared with conventionally fractionated therapy. To further improve the therapeutic ratio, our current protocol has been amended by reducing the large field dose per fraction to 110 cGy (with a 2 day protraction of overall time) and requiring a minimum interfraction interval of 6 hr.

Multimodal treatment for inflammatory breast cancer

This is a retrospective study of 61 patients with clinically diagnosed breast cancer (IBC) treated with multimodality therapy between September 1977 and September 1985. All patients were scheduled to receive three courses of doxorubicin-based chemotherapy followed by mastectomy, further chemotherapy, and postoperative irradiation. Ten patients (16%) obtained a complete response, defined as either resolution of the clinical signs of inflammatory breast cancer (IBC) (4 patients) or no evidence of tumor in the mastectomy specimen (6 patients). Twenty-seven patients (45%) obtained a partial response, defined as a greater than 50% reduction in the clinical signs of inflammatory breast cancer. No response occurred in 24 patients (39%). Immediate mastectomy was done in 56 patients. Five patients whose disease was not resectable received preoperative irradiation. Nine patients at high risk for locoregional failure received postoperative irradiation immediately after mastectomy and before additional chemotherapy. Postoperative irradiation was given to the chest wall and peripheral lymphatics using standard or accelerated fractionation to a maximum dose of 60 Gy. Forty-six patients completed planned treatment including chemotherapy, surgery, and radiotherapy without failure. The minimum follow-up was 36 months. The 5-year actuarial disease-free survival was 70% for the complete response group, and 35% for the partial response group. All patients with no response failed by 34 months. The actuarial 5-year disease-free survival rate for the entire group was 27%. The 5-year actuarial locoregional control was 89% in the complete response group, 68% in the partial response group, 33% in the no response group, and 58% for all patients. Most failures were on the chest wall within the irradiated volume. Chest wall failures were more frequent in those who did not achieve brisk erythema or moist desquamation after postoperative irradiation. We conclude that multimodal treatment of patients with inflammatory breast cancer results in a low incidence of failure if complete response is obtained following initial chemotherapy. The locoregional control rate and actuarial 5-year disease-free survival for the entire group were not improved when mastectomy was done. Surgery should be done in those patients who respond adequately to chemotherapy, so that late sequelae of high-dose breast irradiation can be eliminated. Higher doses of postoperative irradiation may be required to improve local control in those patients with the poorest response to initial chemotherapy.

Long-range results for breast cancer patients treated by radical mastectomy and postoperative radiation without adjuvant chemotherapy: an update

Between 1963 and 1977, 941 patients with carcinoma of the breast received, at the University of Texas M.D. Anderson Cancer Center, peripheral lymphatic irradiation alone or with chest wall irradiation after a radical or modified radical mastectomy. None of the patients received adjuvant chemotherapy. The incidence of patients with histologically involved axillary nodes was 70%. The lymphatics of the apex of the axilla, of the supraclavicular area, and of the internal mammary chain were irradiated in patients with histologically positive axillary nodes and/or in patients with central or inner quadrant primaries regardless of the axillary status. When in 1963 an electron beam became available, chest wall irradiation has been added to the peripheral lymphatics irradiation, primarily when there was a heavy infestation of the axillary nodes. The disease-free survival curves tend to flatten out at 10 years. At 10 and 20 years, the disease-free survival rates are respectively 55% and 50% for all patients, 44% and 40% for all patients with positive nodes, 56% and 48% for the patients with one to three positive nodes, and 33% and 30% for the patients with four or more positive nodes. The comparison of the mortality curves between the general population and the breast cancer patients seems to indicate a cured fraction, since the curves become parallel at 17 years. The highest incidence of failures is between 0 and 5 years, still a significant incidence between 5 and 10 years, but after 10 years the incidence of failures is relatively small.

Definitive radiotherapy for squamous cell carcinoma of the tonsillar fossa

Between July 1968 and December 1983, 150 patients with previously untreated squamous cell carcinomas of the tonsillar fossa received megavoltage external beam irradiation with curative intent at U.T.M.D. Anderson Cancer Center. These patients were treated following a series of patients who had received radiotherapy between 1954 and May 1968. One hundred and thirty-seven patients were treated with conventional fractionation, the mean doses to the primary being 64.3 Gy, 67.8 Gy, 70.2 Gy, and 72.6 Gy for T1, T2, T3, and T4 lesions respectively. Thirteen patients were treated by altered fractionation schedules, 7 by hyperfractionation, and 6 by a concomitant boost to the primary. Elective bilateral neck irradiation was routine in all patients. A planned neck dissection was performed in 26 patients. The 5-year actuarial overall and disease-specific survival rates were 47% and 70%, respectively. Absolute local control rates with a minimum of 2 years follow-up after irradiation were 94%, 79%, 58%, and 50% for patients with T1, T2, T3, and T4 disease respectively. A total of 37 patients had local treatment failure; in 5 of 18 surgical salvage was successful. Only 4 patients with primary disease control developed failure in the neck and none of those with N0 or N1 disease did so when the primary was controlled. Twelve patients developed transient self-limited bone exposure, 7 developed osteoradionecrosis of the mandible, all requiring surgical resection. Most severe late complications occurred in patients with T3 and T4 lesions whose dose to the primary exceeded 67.5 Gy.

Palliative radiotherapy for brain metastases in renal carcinoma

Between 1968 and 1985, 46 patients with renal cell carcinoma metastatic to the brain parenchyma were treated with radiation. Thirty-nine received whole-brain radiation, mostly 30 Gy in ten fractions. Symptoms improved in 30% of evaluable patients. Partial regression of metastases was documented in two of 11 available sequential computed tomographs (CT) of the brain. Seven patients were treated with surgery and postoperative radiation. In five the excision was complete and associated with clinical improvement. All 46 patients have subsequently died. The median survival time of the entire group was 8 weeks. The ten patients who improved after radiotherapy survived for a median of 17 weeks. Two additional patients were treated in 1986 with fast neutrons; both had a documented maintained complete response. Brain metastasis in renal carcinoma carries a poor prognosis. It is usually unresponsive to conventional photon therapy. In selected cases an alternative treatment with surgery or neutron therapy should be considered.

The role of radiation therapy in stages A2 and B adenocarcinoma of the prostate

Between 1965 and 1982 definitive external beam radiation therapy was given to 114 patients with clinically Staged A2 (32 patients) and B (82 patients) adenocarcinoma of the prostate. These patients were not considered to be surgical candidates because of age, comorbidity or disease extent, or because they had refused surgery. Total prostatic doses ranged from 60 to 70 Gy. For 90 surviving patients, follow-up duration ranged from 32 to 188 months with a median of 5 years. The 5- and 10-year uncorrected survival rates for all patients, which were 89% and 68% respectively, were no different from the survival expectation of age-matched men in the general population. Disease-free survival rates at the same time periods were 89% and 86%. There were no significant differences in disease-free survival between Stage A2 and Stage B. Four patients (3.5%) developed local recurrence. Bone metastases, which occurred in 9 of 11 treatment failures were the predominant cause of failure. An analysis of 11 potential prognostic factors was fruitless. Pelvic node irradiation did not improve the outcome. The incidence of complications was acceptable. Anorectal problems developed in 20% of patients and urinary manifestations occurred in 20%, and only 2 patients (1.8%) developed serious problems. We concluded that localized external beam high-energy radiation therapy provides excellent local control for disease limited to the prostate, with survival rates that rival those of radical surgery.

Acute and late toxicity associated with sequential bleomycin-containing chemotherapy regimens and radiation therapy in the treatment of carcinoma of the nasopharynx

Between 1975 and 1984, 33 patients with squamous cell carcinoma of the nasopharynx received adjuvant chemotherapy before and/or after definitive radiotherapy at UT M. D. Anderson Hospital. The favored chemotherapy regimens during this time were BCMF (bleomycin, cyclophosphamide, methotrexate, and 5-FU) and PMB (cisplatinum, methotrexate, and bleomycin). Total radiation doses to the primary site averaged 65 Gy for T1 and T2 lesions and 70 Gy for T3 and T4 lesions. Neck nodes were given boost treatments to a maximum of 70 Gy, depending on the extent of the disease. The outcome of treatment in these patients was compared to that of a stage-matched group of 71 patients treated during the same time period with radiotherapy alone. However, the groups were not matched with regard to histologic subtypes: 45% of the radiation-only group had prognostically unfavorable keratinizing squamous carcinomas (WHO 1) compared with 18% of the combined modality group. Overall disease-free survival at 5 years was 63% in the combined modality group and 44% in the radiation only group (p = 0.15). Both acute reactions and late treatment complications were much more frequent and severe in patients receiving combined modality treatment. In patients treated with chemotherapy prior to radiation therapy, 10/20 (50%) experienced severe acute toxicity (RTOG Grade 3 or 4) versus 9/71 (13%) in the radiotherapy-only group. Severe late normal tissue injury occurred in 15/33 (45%) of the combined modality group versus 5/71 (7.0%) in the control group. The majority of the late complications in the adjuvant chemotherapy group consisted of severe soft tissue and muscle fibrosis. The average total bleomycin dose in the patients with severe late soft tissue and muscle fibrosis was 336 mg. The actuarial risk of developing a severe late complication by 2 years after treatment was 68% in the combined modality group versus 8% in the radiation-therapy-only group (p = .001). The probability of remaining both disease-free and complication-free at 5 years was 40% in the radiation-only group and 22% in the combined-modality group (p = 0.08). Comparison of these results with other published reports emphasizes the importance of late toxicity data in assessing the ultimate value of combined modality therapy.

Prognostic implications of age in breast cancer patients treated with tumorectomy and irradiation or with mastectomy

Conservation breast treatment is of particular interest to young women, but whether saving the breast carries a penalty in shorter survival or local-regional recurrent disease has not been well-established. At The University of Texas M.D. Anderson Hospital and Tumor Institute at Houston, 1161 patients treated prior to 1983 with Stage I or II breast cancer were reviewed. Of these patients, 378 were treated with tumorectomy plus irradiation, and 783 were treated with radical or modified radical mastectomy. The two patient groups were compared relative to local-regional disease recurrence and overall and disease-free survivals. Local recurrences in the breast appear to be more frequent in patients less than or equal to 35 years of age treated with tumorectomy and irradiation than in patients older than 35 years, but in patients aged less than or equal to 50 or greater than 50 or less than or equal to 35 or greater than 35 years, there was no significant statistical difference between tumorectomy and irradiation or mastectomy nor was there a difference in disease-free survival. Overall survival rates favored patients treated by tumorectomy and irradiation.

Safety of adjunctive transvaginal beam therapy in the treatment of squamous cell carcinoma of the uterine cervix

At The University of Texas M. D. Anderson Hospital and Tumor Institute at Houston between 1970 and 1980, 159 patients with bulky cervical cancers of FIGO Stages IB or II were treated with transvaginal orthovoltage radiotherapy (TVR) as an adjunct to standard external beam megavoltage irradiation and brachytherapy. The majority received 10 or 15 Gy air dose in 2-3 fractions using 125-250 kVp X rays. The dose from TVR was ignored in subsequent standard treatment planning. The absolute 5-year local control and survival rates were 82 and 83%, respectively. A total of 9 patients (5.7%) developed serious treatment complications that were significantly related to performance of a staging lymphadenectomy prior to radiotherapy and to an external beam pelvic dose of 50 +/- 0.5 Gy versus 40 +/- 0.5 Gy. The risk complications was not related to the dose of TVR or brachytherapy within the ranges used. Provided patients are properly selected and appropriate technical precautions are exercised, TVR is a safe technique. It is effective in controlling bleeding and shrinking large exophytic tumors, and very likely contributes to improved tumor control by facilitating optimal geometry for intracavitary therapy.

Stage C adenocarcinoma of the prostate. An analysis of 551 patients treated with external beam radiation

We retrospectively reviewed records of 551 patients with clinical Stage C prostatic adenocarcinoma treated with 60 to 70 Gy external beam radiation. Elective pelvic node irradiation was given to 247 patients (45%). Follow-up for all surviving patients ranged from 16 to 201 months (median, 6.5 years; mean, 7 years). The 5-, 10-, and 15-year uncorrected actuarial survival rates were 72%, 47%, and 27%, respectively. Disease-free survival rates were 59%, 46%, and 40% at the corresponding times. Actuarial local control rates were 88%, 81%, and 75% at 5, 10, and 15 years, respectively. Disease-free survival was adversely affected by high pathologic grade, disease fixed to the pelvic sidewall, invasion of the bladder, prior transurethral resection, hydronephrosis, and elevated serum levels of prostatic acid phosphatase and creatinine. Elective pelvic node irradiation did not improve the outcome. Complications of treatment were acceptable: minor anorectal and/or urinary symptoms, 11%; mild to moderate complications, 19%; serious problems requiring surgery, 3%. It is concluded that localized, high-energy external beam irradiation provides excellent local control of disease, low morbidity, and 5-, 10-, and 15-year survival rates that have not been rivaled by other treatment.

Adjuvant chemotherapy for advanced nasopharyngeal carcinoma

The outcome of therapy is reported in 34 previously untreated patients with advanced-stage (AJC IV) nasopharyngeal carcinoma treated with combination chemotherapy (cisplatin and non-cisplatin based) and sequential radiation therapy. Sixty-nine patients treated with radiotherapy alone were used as a control group. The control group was matched for T and N stage grouping but differed in that 45% had keratinizing squamous carcinoma, 14.5% had nonkeratinizing squamous carcinoma, and 40.6% had undifferentiated carcinoma, compared with 18%, 50%, and 32.4%, respectively in the combined-treatment group. Seventeen of 21 patients (81%) who received chemotherapy followed by radiotherapy achieved complete remission (CR), whereas 11 of 13 patients (85%) who received radiotherapy followed by chemotherapy achieved CR (P = NS). Patients treated by radiotherapy alone had a 91% CR rate. The combined treatment yielded a relapse-free rate of 78% versus 44% for the radiotherapy group (P = 0.001). Median survival in the combined-treatment group has not been reached (111+ months), compared with 67 months in the group receiving radiotherapy alone (P = 0.04). The recurrence rate at the primary site and in regional nodes was more frequent in the radiotherapy group (36%), compared with the combined-therapy group (7%) (P = 0.004), but the occurrence of distant metastases was similar in each group (P = 0.41). The acute toxicity of the treatment was well tolerated. The major long-term toxic effect experienced by patients in the combined-therapy group was soft tissue fibrosis. These data suggest that a prospective trial comparing chemotherapy and radiotherapy versus radiotherapy alone is warranted.