Treatment of breast abscesses with sonographically guided aspiration, irrigation, and instillation of antibiotics

OBJECTIVE

We studied the feasibility of treating breast abscesses with sonographically guided aspiration, irrigation, and local instillation of antibiotics without placing indwelling catheters.

MATERIALS AND METHODS

Seventy-three patients with breast abscesses were seen from 1995 to 2001. Aspiration and irrigation were performed under sonographic guidance. Repeated aspiration was performed when deemed necessary. One gram of cephradine was injected into 29 abscesses measuring more than 25 mm.

RESULTS

Six patients refused further treatment after failure of the first aspiration and elected surgical drainage. Of the remaining 67 patients who completed treatment, 38 required one aspiration for cure, 18 required two aspirations, and eight required more than two aspirations. The treatment failed and surgical drainage was required in only three of the 67 patients completing treatment.

CONCLUSION

Ninety-six percent of patients completing treatment were cured with this procedure. Local instillation of antibiotics is probably beneficial.

Revisiting the mammographic follow-up of BI-RADS category 3 lesions

OBJECTIVE

Using data collected for one series during 1987-1989 and data collected for another series during 1996, we sought to compare the frequency of and positive predictive value for carcinoma of the breast in nonpalpable, probably benign lesions that had been detected on and followed up with mammography.

MATERIALS AND METHODS

During 1996, mammography was performed in 18,435 women of whom 544 (3.0%) had lesions assigned to Breast Imaging Reporting and Data System (BI-RADS) category 3 for nonpalpable, probably benign lesions. The lesions in the women were assessed as BI-RADS category 3 after the patients had undergone a diagnostic study that included additional imaging, sonography, and a focused physical examination. Patients with BI-RADS category 3 lesions were recommended for mammographic surveillance. A minimum of 2 years of follow-up data was available for 511 patients, our study population. We compared the findings for our study population with those of the previous study.

RESULTS

Ninety-seven percent of the follow-up mammograms showed stability or regression of the BI-RADS category 3 lesions. Fourteen patients (3%) had nonpalpable interval progression revealed on mammography and underwent biopsy. The breast cancer detection rate in category 3 lesions among the study population was 0.4% (2/511), which was 14% of the patients who had undergone biopsies because of interval progression of the lesions. The pathologic stage of the cancers in these two patients was T1b N0.

CONCLUSION

Compared with the findings from the 1987-1989 study, the frequency of BI-RADS category 3 lesions has remained stable; patient compliance for follow-up has increased; and the positive predictive value of category 3 lesions for cancer has decreased from 1.7% to 0.4% (p = 0.04).

High-dose-rate brachytherapy at 14 Gy per hour to point A: preliminary results of a prospectively designed schedule for cancer of the cervix based on the linear-quadratic model

The objective of this study was to describe the results and complications of a prospectively designed high-dose-rate (HDR) brachytherapy schedule for early-stage cancer of the cervix, at 14 Gy/h to point A, based on the linear-quadratic model and our clinical experience. We used a combination of brachytherapy and external beam pelvic and parametrial irradiation in 88 consecutively seen patients with stage IB1-IIB treated by irradiation alone (1995-1998). The modeled HDR schedule consisted of three insertions on three treatment days separated by 10 days, with six 7 Gy planned brachytherapy fractions to point A, at 14 Gy/h, two on each treatment day with an interfraction interval of 6 h, plus an 18 Gy external whole-pelvic dose followed by additional parametrial irradiation. The calculated biologically effective dose (BED) was 92 Gy10 for tumor and 110 Gy3 for the rectum, equivalent to 77 and 66 Gy in 2 Gy fractions, respectively. The median overall treatment time was 41 days. The actuarial 4-year central recurrence-free rate, pelvic control, and disease-free survival rate were 97%, 93%, and 88% for stages IB-IIA and 79%, 75%, and 75% for stage IIB. The actuarial 4-year late complication rate for grades 2-3 was 4.7% (scale 0-3). We conclude that preliminary results of this HDR brachytherapy schedule for early-stage disease at a median follow-up of 52 months are as effective as the previously used low dose rate (LDR) at 0.44 Gy/h at point A. They are also as effective as medium-dose-rate schedules (MDR) at 1.6-1.5 Gy/h at this institution and do not require a further increase in fractionation of intracavitary treatments or in the whole-pelvic external beam irradiation dose common to standard HDR schedules. In addition, more patients per machine can be treated per day compared with MDR. Longer follow-up is required for a complete assessment of late complications.

Accelerated hyperfractionated irradiation for advanced head and neck cancer: effect of shortening the median treatment duration by 13 days

BACKGROUND AND PURPOSE

Optimal treatment duration of altered fractionation schedules in head and neck cancer is still undefined. A retrospective study on local tumor control, survival, and complications of accelerated hyperfractionated irradiation in head and neck cancer was undertaken to investigate whether there was an advantage in further shortening overall time from 6.5 weeks.

METHODS

Four hundred nineteen consecutive male patients treated with radiation alone for cure 1987-1998 were analyzed. Patients with stage I, or treated also with brachytherapy implants or chemotherapy, were excluded. Treatment with accelerated hyperfractionation was performed twice daily, at a median of 1.6 Gy/fraction, to a total median dose of 68 Gy in 39 days. The patient population was divided into two groups: those with < or =39 days overall treatment time (group A, n = 227; median, 33 days) and those with >39 days (group B, n = 192; median, 46 days). Group A received a significant median tumor dose reduction of 7% compared with group B.

RESULTS

The 7-year actuarial local control (LC) rates were 59% and 48% for groups A and B, respectively (p =.02). The actuarial LC rates for T1-2 patients were 79% and 74% at 7 years for groups A and B, respectively (p = NS). Similarly, for T3-4 patients, they were 47% and 35% (p =.02), respectively. The 7-year actuarial disease-free survival (DFS) rates for groups A and B were 39% and 26% (p =.01), respectively. For stage II patients, DFS was 62% and 60% at 7 years (p = NS) for groups A and B, respectively. And similarly, for stage III-IV patients, DFS was 33% and 20% (p =.04), respectively, at 7 years. LC and DFS rates at 7 years for T4 and stage IV patients, respectively, were significantly improved in group A. Cox regression analyses for LC showed that both T stage and overall time were significant prognostic factors. Similarly, UICC clinical stage and overall time were significant prognostic factors for DFS. There was no difference in acute morbidity between the two groups: 3% of patients in both groups required tube or parenteral feeding. The 7-year actuarial probability of RTOG/EORTC grades 3-5 late effects was 15% and 13%, respectively, for each group (p = NS).

CONCLUSIONS

This study, with the limitations of a retrospective study, has shown a significant improvement in local tumor control and disease-free survival, in patients treated with shorter overall treatment times (median, 33 days) with an accelerated hyperfractionated irradiation schedule compared with those treated with a median duration of 46 days. No significant enhancement of acute reactions and late morbidity were observed with the shorter schedule.

Advanced head and neck carcinoma in women: treatment outcomes may not improve with accelerated hyperfractionated radiotherapy

BACKGROUND

The authors undertook a retrospective study on local tumor control, survival, and complications of conventional irradiation compared with accelerated hyperfractionated irradiation in women with selected head and neck tumor sites.

METHODS

One hundred eight consecutive women who were treated with radiation alone for cure during 1974-1998 were analyzed. Patients were excluded who had T1 tumors of the vocal cord and those who were treated with brachytherapy implants. Fifty-nine patients were treated with conventional fractionation once daily (QD) during 1974-1998 with a median dose of 2.1 grays (Gy) per fraction up to a total median dose of 69 Gy in a median overall time of 54 days. Forty-nine patients were treated with accelerated hyperfractionation twice daily (BID) during 1987-1998 at a median dose of 1.6 Gy per fraction BID, with an interfraction interval of 4-6 hours, for a total median dose of 66 Gy in 35 days. Patients were not randomized into the QD group or the BID group.

RESULTS

The 7-year actuarial local control (LC) rates for T1-T2 tumors in QD-treated and BID-treated patients were 79% and 87%, respectively (P = not significant [NS]). For T3-T4 tumors, the LC rates at 7 years were 59% and 56% for the QD and BID groups, respectively (P = NS). A Cox regression analysis for LC showed that the significant variables were T classification and overall time. Schedule (QD or BID), total dose, dose per fraction, and patient age were not significant variables. For the QD and BID groups, the 7-year actuarial cause specific survival rates for patients with Stage I-II disease were 100% and 65%, respectively (P = 0.004), and, for patients with Stages III-IVA,IVB disease, the rates were 39% and 56%, respectively (P = NS), respectively. Acute morbidity was higher with the BID schedule: In the BID group, 8% of patients required tube or parenteral feeding, and 0% of patients in the QD group required such feeding (P = 0.04). The 5-year actuarial probability of Grade 3-5 late effects (according to the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer grading system) was 4% for the BID group and 0% for the QD group (P = NS).

CONCLUSIONS

This study suggests that accelerated hyperfractionated irradiation for women with advanced carcinoma of the head and neck does not provide significantly better local tumor control or cause specific disease free survival compared with conventional fractionation. Women with these malignancies appear to have a better prognosis compared with men.

Improved results with accelerated hyperfractionated radiotherapy of advanced head and neck cancer

A retrospective study on local tumor control, survival, and complications of conventional irradiation vs. accelerated hyperfractionated irradiation in patients with selected head and neck cancer sites was undertaken. A total of 1,007 consecutive patients treated with radiation alone for cure from 1974-1997 were analyzed. Excluded were female patients, patients with T1 stage of the vocal cord, and patients also treated with brachytherapy implants. There were 637 patients treated with conventional fractionation once daily (QD) in 1974-1997, at a median 2.1 Gy/fraction, to a total median dose of 71.4 Gy in a median overall time of 54 days. As was common before the mid-1980s, 39% and 22% of patients had overall times exceeding 8 and 9 weeks, respectively; 370 patients were treated with accelerated hyperfractionation twice daily (BID) from 1987-1997, at a median of 1.6 Gy/fraction, with an interfraction interval of 4-6 h, to a total median dose of 68 Gy in 40 days. Both schedules were well-balanced with respect to their pretreatment characteristics. Patients were not randomized into QD or BID. The 10-year actuarial probability of local control was 37% vs. 56% for QD and BID, respectively (P < 0.001), which reflects an increase of 19% or a 51% reduction in the local failure rate. Multivariate analysis revealed that T-stage, QD or BID schedule, and overall treatment time were significant independent factors for achieving local tumor control. The 10-year actuarial probability of cause-specific disease-free survival was 25% and 30% for QD and BID, respectively (P = 0.012). Acute morbidity was slightly higher with the BID schedule: patients requiring tube or parenteral feeding were 2.4% for BID and 0.5% for QD (P = 0.01). The 10-year actuarial probability of RTOG/EORTC Grades 3-5 late effects was 13% for both QD and BID. The lack of increase in late complications was most probably due to the lower total dose and dose per fraction in the BID schedule. This study has shown that accelerated hyperfractionated irradiation using two doses of 1.6 Gy each treatment day for less than 6 weeks in advanced head and neck cancer in male patients provides significantly better local tumor control and cause-specific disease-free survival, without increased late morbidity, than conventional fractionation delivered at the previously relaxed overall times of 7 weeks, but sometimes exceeding 8 or 9 weeks. Int. J. Cancer (Radiat. Oncol. Invest.) 90, 80-91, 2000.

Vegetables, fruits, and related nutrients and risk of breast cancer: a case-control study in Uruguay

To evaluate whether the protective effect associated with vegetables and fruits in breast cancer could be explained by nutrients and bioactive substances present in these plant foods, we carried out a case-control study in Uruguay including 400 cases and 405 controls. The intake of vegetables, fruits, and related nutrients was estimated with a food frequency questionnaire on 64 food items. This questionnaire allowed the calculation of total energy intake, and nutrients were calorie adjusted by the residuals method. Odds ratios for study variables were estimated by unconditional multiple logistic regression. Total vegetable, total fruit, dietary fiber, vitamin C, vitamin E, lycopene, folate, and total phytosterol intakes were inversely associated with breast cancer risk [4th quartile odds ratio for total vegetable intake = 0.41, 95% confidence interval = 0.26-0.65, p (for trend) = 0.004]. The association with total vegetable intake was not independent of lycopene intake. The results related to vegetable and nutrient intakes are consistent with antioxidant and antiestrogenic effects. This could be mediated, among other nutrients, by dietary fiber and lycopene intake. The role of other unmeasured phytochemicals, correlated with dietary fiber and lycopene intakes, cannot be ruled out.

Medium-dose-rate brachytherapy of cancer of the cervix: preliminary results of a prospectively designed schedule based on the linear-quadratic model

PURPOSE

To compare results and complications of our previous low-dose-rate (LDR) brachytherapy schedule for early-stage cancer of the cervix, with a prospectively designed medium-dose-rate (MDR) schedule, based on the linear-quadratic model (LQ).

METHODS AND MATERIALS

A combination of brachytherapy, external beam pelvic and parametrial irradiation was used in 102 consecutive Stage Ib-IIb LDR treated patients (1986-1990) and 42 equally staged MDR treated patients (1994-1996). The planned MDR schedule consisted of three insertions on three treatment days with six 8-Gy brachytherapy fractions to Point A, two on each treatment day with an interfraction interval of 6 hours, plus 18 Gy external whole pelvic dose, and followed by additional parametrial irradiation. The calculated biologically effective dose (BED) for tumor was 90 Gy10 and for rectum below 125 Gy3.

RESULTS

In practice the MDR brachytherapy schedule achieved a tumor BED of 86 Gy10 and a rectal BED of 101 Gy3. The latter was better than originally planned due to a reduction from 85% to 77% in the percentage of the mean dose to the rectum in relation to Point A. The mean overall treatment time was 10 days shorter for MDR in comparison with LDR. The 3-year actuarial central control for LDR and MDR was 97% and 98% (p = NS), respectively. The Grades 2 and 3 late complications (scale 0 to 3) were 1% and 2.4%, respectively for LDR (3-year) and MDR (2-year).

CONCLUSIONS

LQ is a reliable tool for designing new schedules with altered fractionation and dose rates. The MDR schedule has proven to be an equivalent treatment schedule compared with LDR, with an additional advantage of having a shorter overall treatment time. The mean rectal BED Gy3 was lower than expected.

Corticosteroids and radiation mucositis in head and neck cancer. A double-blind placebo-controlled randomized trial

Patients with head and neck cancer were randomized in a double-blind manner to receive 40 mg/day prednisone (n = 32) or placebo (n = 34). The prescribed daily tumour dose was 1.6 Gy twice daily with an interfraction interval of > or =6 h. Treatment interruptions were at the discretion of the radiation oncologists. The primary study end-point was the total duration of treatment. A mean 4.4 day reduction was observed in the total elapsed treatment duration for the prednisone arm, 34.3 versus 29.9 days (P = 0.013), which paralleled a significantly lower median total tumour and biologically effective dose (BED) Gy10 in this arm. A trend favouring shorter treatment interruptions in the prednisone arm was also found, but not a reduction in the intensity or duration of mucositis.

Biologically effective doses in medium dose rate brachytherapy of cancer of the cervix

The amount of dose reduction on changing from low dose rate (LDR) brachytherapy to medium dose rate (MDR) or high dose rate (HDR) afterloading has been the subject of much debate. The magnitude of reduction depends, together with other possible factors, on two radiobiological parameters: the alpha/beta ratio and the half-time of repair of the relevant tissues. In an attempt to extract these radiobiological parameters for the late rectal complications observed in our previously published clinical results four different schedules using MDR and one using LDR are analyzed. The percentage incidence of complications was a function of increasing biologically effective dose (BED), but would yield nonsense scattergrams if plotted against raw total dose. In addition, for three other published MDR series, three LDR series, and two HDR series, the incidence of rectal complications is plotted against BED to examine the predictive potential of using BED as the surrogate of total dose. Our own results were published in 1996, consisting of 102 patients treated at the LDR of 0.44 Gy/hr and 88 patients treated by four different schedules using an MDR of 1.6-1.7 Gy/hr. Follow-up is at least 3 years in all schedules. The linear quadratic formula including the "g" dose rate factor was used to analyze them, assuming exponential repair of the repairable beta term. First, multivariate and profile likelihood analyses were carried out to obtain estimates of alpha/beta and T1/2 for rectal late responding tissues. Then graphs of incidence of rectal complications vs. BED were constructed, assuming alpha/beta = 3 Gy and T1/2 = 1.5 hr, values which had not been contradicted by the multivariate analysis. Graphs were drawn both for "all grades including mild reactions" (grades 1 + 2 + 3) and for "serious" complications (grade 3 in our system). In addition, other published cervical brachytherapy series were reviewed, with calculation of their BEDs if not published by the authors. It was necessary to review and compare their grading systems, so that "mild and moderate" (grades 1 and 2) could be contrasted with "serious" (grades 3 and 4 or 5 in various systems). Comparisons were made with other published results, including three LDR, three MDR, and two HDR series spanning from 1982 to 1997. The BEDs at which the incidence of rectal complications rose above the arbitrary level of 10% were compared for all three ranges of dose rate. The multivariate analysis gave estimates of alpha/beta and T1/2 which were not significantly different from 3 Gy and 1.5 hr, respectively, so these values were used to compute the BEDs for the subsequent comparisons. It was found that the graphs of incidence of rectal complications for "all grades including mild" agreed rather better between all series than might have been expected, within a provisional (10%) threshold BED of range 100-123 Gy3 (60-74 Gy given as 2 Gy fractionated external beam or as LDR). The dose-response curves diverged above these values, as expected until common grading systems such as SOMA/ LENT become more widely used. For "serious" complications the 10% incidence occurred at a median BED of 140 Gy3 (84 Gy given as 2 Gy fractionated external beam or as LDR), range 124-155 Gy3. The use of BED (or extrapolated response dose), assuming alpha/beta = 3 Gy and T1/2 = 1.5 hr, instead of total dose, enabled incidence of late rectal complications in cervical brachytherapy with LDR, MDR, and HDR to be plotted in a reasonably consistent way. This does not mean that those parameter values have been definitively determined, but they appear to be provisional values that may be of use in comparing the expected effects of new schedules until better values are obtained from greater use of common grading systems.

Induction chemotherapy and radiotherapy of advanced cancer of the cervix: a pilot study and phase III randomized trial

PURPOSE

This study assessed the effectiveness and toxicity of induction chemotherapy (CT) and radiation therapy (RT) in the treatment of locally advanced carcinoma of the cervix with data provided by a pilot study and a randomized trial.

METHODS AND MATERIALS

Eighty-six patients with International Federation of Gynecology and Obstetrics (FIGO) Stage IB-IVA (Stage IB >4-cm tumor diameter) (Group A) were entered in a pilot study and treated with cisplatin (50 mg/m2), vincristine (1 mg/m2 on days 1, 11, and 21), bleomycin (25 mg/m2 infusion on days 1-3, 11-13, and 21-23), and standard RT. Ninety-six patients were randomized to either this same CT regimen and RT, or RT alone (Group B: CT plus RT or RT).

RESULTS

In Group A, 58% responded to induction CT. With a mean follow-up of 78 months, 73% achieved pelvic control (LRC), and 55% were disease-free survivors. Response to CT was not a marker for ultimate LRC or increased disease-free survival (DFS). In Group B, 62% responded to CT. With a mean follow-up of 43 months, LRC was 68% and 65% for all randomized patients in the CT plus RT and RT arms, respectively (p = NS). In patients who completed treatment, 78% and 70%, respectively, achieved LRC (p = NS). Disease-free survival rates were 38% and 49% for randomized patients in the CT plus RT and RT arms (p = NS), respectively, and 44% and 52% in those patients completing treatment (p = NS), respectively. Complications were acceptable.

CONCLUSION

Data from this study did not prove the efficacy of induction CT before definitive RT in locally advanced cancer of the cervix. Induction CT with the currently used combinations and modes of administration should not be considered standard therapy.

Fractionation in medium dose rate brachytherapy of cancer of the cervix

PURPOSE

To establish an optimum fractionation for medium dose rate (MDR) brachytherapy from retrospective data of patients treated with different MDR schedules in comparison with a low dose rate (LDR) schedule.

METHODS AND MATERIALS

The study population consists of consecutive Stage IB-IIA-IIB patients who received radiotherapy alone with full dose brachytherapy plus external beam pelvic and parametrial irradiation from 1986-1993. Patients also receiving surgery or chemotherapy were excluded. The LDR group (n = 102, median follow-up: 80 months) received a median dose to Point A of two 32.5 Gy fractions at 0.44 Gy/h plus 18 Gy of external whole pelvic irradiation. The MDR1 group (n = 30, median follow-up: 45 months) received a mean dose of two 32 Gy fractions at 1.68 Gy/h. An individual dose reduction of 12.5% was planned for this group according to the Manchester experience, but only a 4.8% dose reduction was achieved. The MDR2 group (n = 10, median follow-up: 36 months) received a dose of two 24 Gy fractions at 1.65 Gy/h. The MDR3 group (n = 10, median follow-up 33 months) received a mean dose of three 15.3 Gy fractions at 1.64 Gy/h. And finally, the MDR4 group (n = 38, median follow-up: 24 months) received six 7.7 Gy fractions from two pulses 6 h apart in each of three insertions at 1.61 Gy/h. The median external pelvic dose to MDR schedules was between 12 and 20 Gy. The linear quadratic (LQ) formula was used to calculate the biologically effective dose (BED) to tumor (Gy10) and rectum (Gy3), assuming T1/2 for repair = 1.5 h.

RESULTS

The crude central recurrence rate was 6% for LDR (mean BED = 95.4 Gy10) and 10% for MDR4 (mean BED = 77.0 Gy10) (p = NS). The remaining MDR groups had no recurrences. Grade 2 and 3 rectal or bladder complications were 0% for LDR (rectal BED = 109 Gy3) 83% for MDR1 (BED = 206 Gy3), and 30% for MDR3 (BED = 127 Gy3). The MDR2 and MDR4 groups presented no complications (BED, 123 Gy3, and 105 Gy3, respectively). The LQ formula appears to correlate with late complications of the different MDR regimens. A BED above 125 Gy3 was associated with Grade 2 + 3 rectal complications. Adequate central tumor control may be compromised with a tumor BED below 90-95 Gy10.

CONCLUSIONS

Medium dose rate brachytherapy at 1.6 Gy/h to Point A has a marked dose rate effect. Increased fractionation is the cost of overcoming the less favorable therapeutic ratio for MDR than for LDR. A larger (25%) reduction of brachytherapy dose than previously reported is also necessary. Our most recently developed schedule for Stage I-II patients is three insertions on three treatment days with six 8.0 Gy brachytherapy fractionations, two on each treatment day, following or preceding an external whole pelvis dose of 18 Gy, and followed by additional external parametrial dose.

Breast conservation treatment of early stage breast cancer: patterns of failure

PURPOSE

This study retrospectively assesses the patterns of failure in conservatively treated early stage breast cancer patients by correlating various clinical, pathologic, and treated-related factors with local, axillary, and distant relapse.

METHODS AND MATERIALS

Between 1973 and 1990, 796 patients (817 breasts) received breast conservation surgery followed by radiotherapy. Local recurrences were counted as events even if they occurred simultaneously or after the appearance of axillary or distant metastases.

RESULTS

The 10-year actuarial relative disease-free survival (DFS) rate for T1N0, T2N0, and T1-2N1 was 82%, 71%, and 54%, respectively. Stage N0 patients had a significant DFS advantage over N1 patients (p = 0.02). The 15-year actuarial local recurrence-free rate for T1 and T2 tumors was 82% and 87%, respectively (p = nonsignificant). Univariate analysis identified three significant risk factors for local relapse: (a) 48 breasts with tumors showing an extensive intraductal component had a crude local recurrence rate of 23% compared to 8% for 769 breasts without intraductal component (p = 0.0016); (b) the actuarial 10-year local recurrence-free rate for patients under age 40 years was 64% compared to 88% for patients over 40 years (p < 0.0001); (c) the 10-year actuarial local recurrence-free rate for 416 postmenopausal women without adjuvant tamoxifen was 83% compared to 97% for 107 postmenopausal women with tamoxifen (p = 0.0479). Salvage therapy for operable local recurrent patients resulted in a 8-year actuarial DFS rate of 47%, significantly lower than that obtained with primary treatment. The incidence of axillary relapse as the first sign of recurrence was 2%, and could be correlated with the lack of axillary dissection (p < 0.0000005) and primary tumor size (p = 0.03). Radiotherapy to the axilla did not influence axillary relapse. Actuarial 5-year DFS rate after treatment of isolated axillary recurrence was 27%. Axillary failure was a marker for distant failure. Contralateral breast cancer occurred in 8% of patients and did not have a detrimental effect on survival. Adjuvant tamoxifen decreased the 9-year actuarial incidence of contralateral breast cancer from 10% to 4% (p = 0.053).

CONCLUSIONS

Tumors with extensive intraductal component, age under 40 years, and the omission of adjuvant tamoxifen in postmenopausal women increased local recurrence rate. Stage T2 and the lack of axillary dissection increased axillary recurrence rate. Stage N+ and local or axillary relapse increased distant failure rate. Axillary irradiation did not influence locoregional control nor survival. Improved therapy is needed for relapsing patients.

Nonpalpable, probably benign lesions: role of follow-up mammography

Of 21,855 consecutive women prospectively studied with mammography, physical examination, and high-resolution ultrasonography when appropriate, 558 received a diagnosis of nonpalpable, probably benign lesions. Follow-up mammography was recommended for these patients. Characteristically benign lesions and palpable masses were excluded from analysis. The positive predictive value for detection of a nonpalpable, probably benign breast lesion was 0.017. Nine patients ultimately proved to have carcinoma; two of them had noninvasive carcinoma, and two had axillary node metastases. The positive predictive value for detection of a nonpalpable, probably malignant lesion was 0.47. The policy of recommending mammographic surveillance for nonpalpable, probably benign lesions, a viable option for radiologists, has the capability of lowering the rate and therefore the costs of biopsy procedures with negative results.

Elective neck irradiation in the treatment of cancer of the oral tongue

A total of 69 patients with squamous cell carcinoma of the oral tongue Stages T1-2-3 N0 were treated between 1952 and 1982 at one cancer center in Montevideo, Uruguay. Of 52 patients with the primary disease controlled, 2 had elective cervical lymph node dissection, and were therefore excluded from the study, 25 were treated with elective neck irradiation, and 25 were followed without irradiation to the neck. In the untreated group, 40% developed neck node metastases, while this was observed only in 20% of the group receiving elective neck irradiation, but only 4% recurred in the elective irradiated areas of the neck (p: 0.0028). The survival was the same for each group (5-year absolute survival with NED 67% for the neck irradiation group and 64% for the unirradiated group). From this retrospective study, we conclude that elective neck irradiation in carcinoma of the oral tongue decreases the incidence of neck metastases but an improvement in survival of these patients was not demonstrated.

The place of brachytherapy in the treatment of carcinoma of the tonsil with lingual extension

One hundred forty-four of 170 patients (85%) were seen with cancer of the tonsil and received radical irradiation between 1959 and 1980. A 39% crude 3-year disease-free survival rate and a 51% locoregional control rate were observed. Locoregional relapse related to T Stage was 6, 43, 58, and 64% for T1, T2, T3, and T4, respectively. Fifty-four of 144 patients (37%) showed tongue extension, 20% in T1-T2 stages and 50% in T3-T4 stages. Local relapse was 64% and the 3-year disease-free survival rate was 23% in 39 patients with tongue extension treated with external irradiation alone, versus 33 and 43% respectively for 90 patients with no tongue extension. The increase of lymph node metastases or neck recurrences was not related to tongue extension. In 15 patients with tongue extension, treated with external radiation plus brachytherapy, the local relapse was 40% and the 3-year survival rate 60%. External irradiation plus brachytherapy was significantly related to lower local relapse and increased survival rate compared to external irradiation alone in cancer of the tonsil with tongue extension. The combined modality was not associated with increased risk of radiation complications.

Lymphangiosarcoma of the anterior abdominal wall: a case report

A rare case of lymphangiosarcoma of the anterior abdominal wall arising in chronic lymphedema following radical vulvectomy with bilateral inguinal lymphadenectomy and postoperative radiotherapy is reported. This is apparently the first description of this association, and the second reported case of lymphangiosarcoma originating in the anterior abdominal wall.

[Therapeutic decisions. What is the value of radiotherapy in the treatment of adenocarcinoma of the endometrium?]

Total hysterectomy is the most important step in the management of endometrial carcinoma.70% of endometrial carcinomas are seen in post menopausal women. Staging of these tumors depends on the histological type, the degree of penetration of these tumors and the presence of metastatic extension. Clinical evaluation of these patients, lymphangiography and surgical evaluation will complete the proper staging of the patients. Radiotherapy can be used associated with surgery either pre-surgically or post-surgically or as the only form of treatment, in those cases that are technically unresectable or with surgical contraindications or in the management of recurrent tumors or metastasis. The most widely used pre-op radiation has been intracavitary radiation following the Heyman packing technique. Some authors recommend external radiation of the pelvis with megavoltage doses of 4,000-5,000 rads and sometimes the association of internal-external radiation. Five years survival depends on staging of the disease and can vary from 75%-50%-25% or 5% for stages I through IV respectively. The incidence of vaginal metastasis after hysterectomy varies between 10-15% as opposed to an incidence of -4% after radiation.

[Plummer-Vinson syndrome]

The Plummer-Vinson syndrome is very uncommon in Latin America. Four cases showing the clinical-radiological and hematological features of this syndrome are described. Three cases were treated with esophageal dilatation and Ferro therapy. The radiological evaluation may show deformities in the faringo-esophageal lumen other than the esophageal webs, such as hypertrophy of the cricopharingeal sphincter and of the retrocricoid venous plexus as well as the demonstration of esophageal webs in the patients without symptoms or signs of the Plummer Vinson Syndrome.