Survival benefit of adjuvant radiotherapy in stage III and IV bladder cancer: results of 170 patients

Background:

Radical cystectomy (RC) with or without neoadjuvant chemotherapy is the standard treatment for muscle-invasive bladder cancers. However, the locoregional recurrence rate is still significantly higher for locally advanced cases post-RC. The underuse of postoperative radiotherapy (PORT) in such cases after RC is related mainly to a lack of proven survival benefit. Here we are reporting our long-term Egyptian experience with bladder cancer patients treated with up-front RC with or without conformal PORT.

Patients and methods:

This retrospective study included 170 locally advanced bladder cancer (T3–T4, N0/N1, M0) patients who had RC performed with or without PORT at Damietta Cancer Institute during the period of 1998–2006. The treatment outcomes and toxicity profile of PORT were evaluated and compared with those of a non-PORT group of patients.

Results:

Ninety-two patients received PORT; 78 did not. At median follow-up of 47 months (range, 17–77 months), 33% locoregional recurrences were seen in the PORT group versus 55% in the non-PORT group (P<0.001). The overall distant metastasis rate in the whole group was 39%, with no difference between the two groups. The 5-year disease-free survival for the whole group of patients was 53%±11%, which was significantly affected by additional PORT, and 65%±13% compared with 40%±9% for the non-PORT group (P=0.04). The pathological subtypes did not affect 5-year disease-free survival significantly (P=0.9). The 5-year overall survival was 44%±10%. Using multivariate analysis, PORT, stage, and extravesical extension (positive surgical margins) were found to be important prognostic factors for locoregional control. Stage and lymph node status were important prognosticators for distant metastasis control.

Conclusion:

PORT was found to be a safe and effective tool in decreasing local recurrence rates and improving disease-free survival.

Postoperative radiotherapy for gallbladder cancer

AIM

To evaluate the results of postoperative radiotherapy (PORT) and to identify prognostic factors for gallbladder cancer (GBC).

PATIENTS AND METHODS

We retrospectively analyzed 86 patients with GBC who underwent potentially curative surgical resection and PORT between November 1993 and December 2009. All patients received three-dimensional conformal radiotherapy and 61 patients (71%) had concurrent chemotherapy. Survival outcomes including locoregional control (LRC), disease-free survival (DFS) and overall survival (OS) rates were analyzed.

RESULTS

The median follow-up period was 83 months for surviving patients. The 5-year OS, DFS and LRC rates were 42%, 36% and 73%, respectively. Isolated locoregional recurrence as first failure occurred in seven patients (8%). On multivariate analysis, the postoperative carbohydrate antigen 19-9 (CA 19-9) level was a significant prognostic factor for LRC, DFS and OS.

CONCLUSION

Adjuvant radiotherapy might be an effective treatment in terms of LRC in GBC. Postoperative CA 19-9 might be useful as a surrogate marker for survival.

Locoregional recurrence of triple-negative breast cancer: effect of type of surgery and adjuvant postoperative radiotherapy

Background/purpose

The aim was to evaluate the prognostic significance of postoperative radiotherapy (PORT) and surgical type on local recurrence-free survival (LRFS) and overall survival (OS) in triple-negative breast cancer (TNBC) in the Egyptian population.

Patients and methods

We evaluated 111 patients with stage I–III TNBC diagnosed at our institute during the period from 2004 to 2009. Patients were stratified according to PORT into two groups: a PORT group and a non-PORT group. The influence of PORT and surgical type on LRFS and OS were evaluated. A cross-matching was done to the non-TNBC group of patients to compare the recurrence and survival rates between them and the studied group of TNBC patients.

Results

The mean age of TNBC patients at diagnosis was 63±7 years. The majority of the patients had stage III disease (68.5%) and 73% had clinical or pathological positive lymph nodes. Sixty percent (67/111) of patients had modified radical mastectomy and 44/111 (40%) patients had breast-conserving treatment. PORT was given for 63% of patients, while systemic treatment was given in 89% of patients. At the time of analysis, 13 patients (11%) developed local recurrence: five of 70 (7%) in the PORT group and eight of 41 (19.5%) in the non-PORT group. Five-year LRFS for the whole group of patients was 88%±6%, which was significantly affected by PORT. The surgical type did not affect local recurrence significantly. Five-year OS for the whole group was 54%±8%. PORT and surgical type did not affect OS significantly (P-value 0.09 and 0.11, respectively). Five-year LRFS was 88%±6% and 90%±11% for TNBC and non-TNBC patients, respectively (P-value 0.8); however, OS for TNBC was significantly lower than for non-TNBC (P-value 0.04).

Conclusion

TNBC is an aggressive entity compared with other non-TNBC, and these patients benefit from PORT significantly to decrease the risk of local recurrence in all stages. However, further large, prospective, randomized trials are warranted.

Postoperative radiation therapy for parotid pleomorphic adenoma with close or positive margins: treatment outcomes and toxicities

AIM

To evaluate the locoregional control and treatment toxicity of patients with pleomorphic adenoma after resection with close or positive margins followed by postoperative radiation therapy (PORT).

PATIENTS AND METHODS

Between 2002 and 2011, twenty-one patients underwent PORT at the Mount Sinai Beth Israel Medical Center for pleomorphic adenoma of the parotid with close or positive margins. Four out of the 21 patients (19%) had recurrent lesions. The median dose was 57.6 Gy (range 55.8-69.96) delivered at 1.8-2.12 Gy/fraction. Treatment and follow-up data were retrospectively analyzed for locoregional control as well as acute- and late-treatment toxicities. Actuarial survival analysis was also performed.

RESULTS

Twelve women and 9 men with a median age of 46 (26-65) at PORT were included in this study. Eighty-one percent of the cohort had positive resection margins while 19% had close margins. At a median follow-up of 92 months, 19/21 patients (90%) had locoregional control. Two patients who failed had primary lesions which recurred locally, and initially had positive margins. The two recurrences occurred at 8 months and 12 months. Acute Radiation Therapy Oncology Group (RTOG) grade 1 and 2 toxicities were experienced by 11 (52%) and 4 (19%) patients, respectively, while 2 (10%) experienced late RTOG grade 1 toxicities. No patients experienced any grade 2-4 late toxicities. Actuarial survival was 100%.

CONCLUSION

PORT for patients with pleomorphic adenoma of the parotid gland after resection with close or positive margins results in excellent locoregional control and low treatment-related morbidity.

Direct effect of radiation on the peripheral nerve in a rat model

Radiation neuropathy is one of the severe complications of radiotherapy. Entrapment neuropathy, caused by surrounding soft tissue fibrosis induced by radiation, plays a key role in the onset of this neuropathy. Meanwhile, the pathophysiology of the direct effect of radiation on the peripheral nerve is not yet fully understood. The aim of this study is to investigate the direct effects of radiation on rat sciatic nerves that are isolated from surrounding soft tissue. In the radiation group (R group), only the exposed sciatic nerve was irradiated with 90 Gy X-radiation. In the sham group (S group), the surgical procedures were completed without radiation. The sciatic functional index (SFI) result demonstrated no statistical differences between the R group and S group. However, even though the surrounding soft tissue was not irradiated, the macroscopic and histological findings of the R group at 24 weeks after radiation showed scar formation around the radiated nerve. These findings on radiation neuropathy indicate that neurohumoral factors derived from the radiated nerve itself may cause fibrosis. The electromyographic and histological examination showed axonal degeneration in the R group. Furthermore, the axon diameter and axon packing density in the R group demonstrated the axonal degeneration, even though it was 0.5 cm more proximal to the radiated portion than the axon packing density in the S group. This appearance was assumed to be "dying-back" neuropathy. It is believed that this study is a first step toward identifying an accurate pathophysiology for intractable radiation-induced peripheral neuropathy.

Primary lymphoepithelioma-like carcinoma of salivary gland: sixty-nine cases with long-term follow-up

BACKGROUND

Lymphoepithelioma-like carcinoma (LELC) in the salivary glands is a rare but unique malignancy.

METHODS

Sixty-nine patients with salivary gland LELC with long-term follow-up were reviewed for this study.

RESULTS

There were 52 cases in the parotid gland and 17 cases in the submandibular gland. All patients underwent complete tumor excision, 41 underwent neck dissection, and 39 received postoperative radiotherapy. The 5-year, 10-year, and 15-year overall survival (OS) rates were 90%, 75%, and 54%, respectively. Patients with higher neutrophil/lymphocyte ratio (NLR ≥ 4.0) and advanced stage (stage III and IV) had significantly poorer OS. Patients who received postoperative radiotherapy had significantly better relapse-free survival (RFS). In multivariate analysis, stage, NLR, and neck dissection were associated independently with OS, whereas stage and postoperative radiotherapy were associated independently with RFS.

CONCLUSION

Salivary gland LELC is a rare malignancy with a better prognosis that partially attributes to surgery with neck dissection and postoperative radiotherapy. Preoperative NLR is an independent prognostic factor.

Postoperative radiotherapy in patients with salivary duct carcinoma: clinical outcomes and prognostic factors

This study sought to investigate the clinical outcome and the role of postoperative radiotherapy for patients with salivary duct carcinoma (SDC) who had undergone surgery and postoperative radiotherapy. We performed a retrospective analysis of 25 SDC patients treated between 1998 and 2011 with surgery and postoperative radiotherapy. The median prescribed dose was 60 Gy (range, 49.5-61.4 Gy). The clinical target volume (CTV) was defined as the tumor bed in four patients, the tumor bed and ipsilateral neck in 14 patients, and the tumor bed and bilateral neck in six patients. Local control (LC), disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method, and prognostic variables were analyzed with the log-rank test. The 5-year LC, DFS and OS were 67%, 45% and 47%, respectively. Disease recurrence was found in 12 patients: seven as local, four as regional and eight as distant failure. Perineural and lymphovascular invasion was a significant prognostic factor for LC (P = 0.03). Local failure was common, and the presence of local recurrence significantly affected the OS (P < 0.05). We conclude that surgery and postoperative radiotherapy is expected to decrease the risk of local failure and contribute to good prognoses for patients with SDC. It might be advisable to have the CTV include the cranial nerves involved and the corresponding parts of the skull base in cases of pathologically positive perineural invasion.

Clinical outcome and patterns of recurrence of head and neck squamous cell carcinoma with a limited field of postoperative radiotherapy

BACKGROUND

Postoperative radiotherapy is the standard treatment for head and neck squamous cell carcinoma having high-risk features in surgical specimens. However, its severe toxicity can be a significant problem. This study was undertaken to evaluate the efficacy of our limited-field postoperative radiotherapy with the aim of reducing morbidity by minimizing the radiation field.

METHODS

Between 2000 and 2009, 154 patients with head and neck squamous cell carcinoma received limited-field postoperative radiotherapy. The reason for postoperative radiotherapy was close/positive margins in 33 patients and extracapsular extension in 91. The median radiation dose was 50 Gy (30-66.4). The radiation field covered the tumor bed without lymph node regions for close/positive margins and only involved sites of the neck region were irradiated for multiple nodes or extracapsular extension.

RESULTS

With a median follow-up of 43 months for surviving patients, the 3-year overall survival and progression-free survival rates were 53.7 and 42.1%, respectively. The 3-year rates of progression-free survival of the group having major risks (i.e. close/positive margins and/or extracapsular extension) and the group with other risks were 34.7 and 62.8%, respectively (P < 0.01). Thirty-one local recurrences (20%), of which 22 were located out-of-field, and 44 regional recurrences (29%), of which 16 were located out-of-field, developed. Late toxicity of grade 3 or greater developed in only six patients (3.8%).

CONCLUSIONS

Although the toxicities associated with limited-field postoperative radiotherapy could be kept to lower levels, the locoregional control rate did not seem to be sufficient. We should arrange the radiation field depending on risk factors.

Postoperative radiotherapy for uterine cervical cancer: impact of lymph node and histological type on survival

AIM

To retrospectively analyze the treatment results of postoperative radiotherapy (PORT) in patients with early-stage uterine cervical cancer.

PATIENTS AND METHODS

Records of 141 patients with stage IB-IIB uterine cervical cancer treated with PORT from 1985 to 2004 were retrospectively reviewed. The majority of patients received whole-pelvic radiotherapy with antero-posterior fields, and the total radiation doses ranged from 10.8-60 Gy (median: 50.4 Gy). The median follow-up of all 141 patients was 106 months (range: 0.8-273.7 months).

RESULTS

Multivariate analysis revealed that positive lymph node status (p=0.001) and histological type (p=0.015) were independent prognostic factors for overall survival. The group with three or more involved lymph nodes was significantly more likely to have extra-pelvic recurrence when compared with the groups with no (p=0.006) and up to two lymph nodes (p=0.024), respectively.

CONCLUSION

PORT yielded excellent pelvic control rates for early-stage uterine cervical cancer. Lymph node status and histological type were significant prognostic factors for overall survival of patients with these tumors.

The role of postoperative radiotherapy in prostate cancer patients

AIM OF THE STUDY

The aim of the study was to evaluate the effectiveness of postoperative radiotherapy in prostate cancer patients with unfavorable prognostic factors.

MATERIAL AND METHODS

In the years 2002-2008, 121 consecutive prostate cancer patients underwent radical prostatectomy and postoperative radiotherapy. The median dose was 64 Gy (range: 60-72 Gy). Biochemical and clinical progression-free survival were estimated. Univariate and multivariate analyses were used to analyze clinicopathological variables associated with treatment failure.

RESULTS

The median follow-up was 27 months. Three-year bPFS was 72%. On univariate analysis it was influenced by: extracapsular tumor extension (60% vs. 75%, p = 0.0232), seminal vesicles invasion (52% vs. 85%, p = 0.00041), Gleason score ≥ 7 (65% vs. 86%, p = 0.044) and the use of hormonal therapy (50% vs. 80%, p = 0.0058). On multivariate analysis bPFS was associated with: TNM stage (HR = 3.19), postoperative hormonal therapy (HR = 2.6), total irradiation dose (HR = 0.82) and the maximum pretreatment level of prostate-specific antigen (PSA) (HR = 0.95). Three-year cPFS was 84%. On univariate analysis it was influenced by: preoperative PSA level > 10 ng/ml (75% vs. 90%, p = 0.04), vascular-nerve bundles involvement (63% vs. 88%, p = 0.0031), adjacent organs infiltration (50% vs. 85%, p = 0.018) and the use of postoperative hormonal therapy (62% vs. 90%, p = 0.02). On multivariate analysis cPFS was associated with: TNM stage (HR = 2.68), postoperative hormonal therapy (HR = 3.61) and total irradiation dose (HR = 0.78).

CONCLUSIONS

Postoperative radiotherapy in patients with unfavorable prognostic factors provides good biochemical and local control. Total irradiation dose and postoperative hormonal therapy are important treatment factors influencing prognosis.

Accelerated hyperfractionation (AHF) compared to conventional fractionation (CF) in the postoperative radiotherapy of locally advanced head and neck cancer: influence of proliferation

Based on the assumption that an accelerated proliferation process prevails in tumour cell residues after surgery, the possibility that treatment acceleration would offer a therapeutic advantage in postoperative radiotherapy of locally advanced head and neck cancer was investigated. The value of T(pot) in predicting the treatment outcome and in selecting patients for accelerated fractionation was tested. Seventy patients with (T2/N1-N2) or (T3-4/any N) squamous cell carcinoma of the oral cavity, larynx and hypopharynx who underwent radical surgery, were randomized to either (a) accelerated hyperfractionation: 46.2 Gy per 12 days, 1.4 Gy per fraction, three fractions per day with 6 h interfraction interval, treating 6 days per week or (b) Conventional fractionation: 60 Gy per 6 weeks, 2 Gy per fraction, treating 5 days per week. The 3-year locoregional control rate was significantly better in the accelerated hyperfractionation (88 +/- 4%) than in the CF (57+/- 9%) group, P=0.01 (and this was confirmed by multivariate analysis), but the difference in survival (60 +/- 10% vs 46 +/- 9%) was not significant (P=0.29). The favourable influence of a short treatment time was further substantiated by demonstrating the importance of the gap between surgery and radiotherapy and the overall treatment time between surgery and end of radiotherapy. Early mucositis progressed more rapidly and was more severe in the accelerated hyperfractionation group; reflecting a faster rate of dose accumulation. Xerostomia was experienced by all patients with a tendency to be more severe after accelerated hyperfractionation. Fibrosis and oedema also tended to be more frequent after accelerated hyperfractionation and probably represent consequential reactions. T(pot) showed a correlation with disease-free survival in a univariate analysis but did not prove to be an independent factor. Moreover, the use of the minimum and corrected P-values did not identify a significant cut-off. Compared to conventional fractionation, accelerated hyperfractionation did not seem to offer a survival advantage in fast tumours though a better local control rate was noted. This limits the use of T(pot) as a guide for selecting patients for accelerated hyperfractionation. For slowly growing tumours, tumour control and survival probabilities were not significantly different in the conventional fractionation and accelerated hyperfractionation groups. A rapid tumour growth was associated with a higher risk of distant metastases (P=0.01). In conclusion, tumour cell repopulation seems to be an important determinant of postoperative radiotherapy of locally advanced head and neck cancer despite lack of a definite association between T(pot) and treatment outcome. In fast growing tumours accelerated hyperfractionation provided an improved local control but without a survival advantage. To gain a full benefit from treatment acceleration, the surgery-radiotherapy gap and the overall treatment time should not exceed 6 and 10 weeks respectively.