Radical treatment for oesophageal cancer patients unfit for surgery and chemotherapy. A 10-year experience from the Norwegian Radium Hospital

BACKGROUND

Over a 10-year period from 1990, 445 patients with carcinoma of the oesophagus were admitted to the Norwegian Radium Hospital and 184 of these patients received treatment with curative intent. Even though surgery is the treatment of choice for these patients, many of them suffer from medical conditions that increase the risk for postoperative mortality and morbidity. In a retrospective study, the effect of the curative treatment offered to patients was explored with a particular focus on patients unfit for surgery.

METHODS

Medical data of the 184 patients treated with curative intent were reviewed and additional clinical information was retrieved from local hospitals and general practitioners. Preoperative radiotherapy followed by surgery was the standard curative treatment for operable patients. Medically inoperable patients were offered radical split-course hyperfractionated radiotherapy followed by a brachytherapy boost.

RESULTS

More than 50% (103/184) received non-surgical treatment only. Patients who received radical surgery (n = 81) were younger, had better performance status, less weight loss and dysphagia compared to patients treated with radical radiotherapy (n = 102). One patient received only photodynamic therapy. The 3-year survival was 29% for patients treated with radical surgery, and 8% for patients who received radical radiotherapy. The overall median crude survival for the two groups of patients were 20 months and seven months respectively.

CONCLUSION

The hyperfractionated radiotherapy provided symptom relief without extensive toxicity and with a possibility for cure for patients with oesophageal cancer who are unfit for surgery and chemoradiotherapy. The literature supports the curative potential of high dose accelerated hyperfractionated radiotherapy even though the optimal radiotherapy regimen still needs to be explored.

Endobronchial radiotherapy for malignant bronchial obstruction or recurrence

Forty-five lung cancer patients who had recurrence and/or endobronchial obstruction were treated with intrabronchial radiotherapy (IBRT). The majority had been heavily treated previously, mainly by external radiotherapy; six patients were treated surgically. IBRT was given with high-dose-rate equipment, either 18 Gy in three fractions or 15 Gy as a single dose was originally planned. For different reasons several patients received other regimens. Palliation of dyspnoea was obtained in 64% of the patients. Palliation of hemoptysis (12/14) and cough (11/17) was registered, as well as improvement in atelectasis in 11/26 patients. Palliation of dyspnoea was enhanced with an IBRT dose > 15 Gy. The median survival after IBRT was 13 weeks. Fatal hemoptysis (FH) occurred in 12 patients; 10 of these within 6 months after treatment. The risk of FH significantly increased with an IBRT dose > 15 Gy.

[Colonic perforation during combined steroid and radiotherapy. Diagnosis and treatment]

Eight patients with colon perforations after combined treatment with radiotherapy and steroid medication are studied retrospectively. Sigmoid diverticuli perforated after a minimum of 5 days treatment. The main symptom was a varying degree of abdominal pain. Clinical parameters were of limited value. The most important single examination was plain abdominal x-ray, though this was not positive in all cases. Seven patients were operated on, one with simple suture, the rest with Hartmann's procedure. None developed postoperative peritonitis. One died from cerebral infarction. Four died within 38 days postoperatively after discharge from hospital. Abdominal symptoms during high dose steroid treatment may indicate perforation of the colon. Immediate operative intervention may have an uncomplicated postoperative course.

Chemoradiotherapy of anal carcinoma: tumour response and acute toxicity

This study was performed to evaluate local tumour control and toxicity of chemoradiotherapy given to patients with primary or recurrent carcinoma of the anal canal. A total of 117 patients were admitted to the Norwegian Radium Hospital during the period of 1983-1989, of which 106 received a combination of radiotherapy (50 Gy to the pelvis) and chemotherapy (mitomycin C + 5-fluorouracil). Sixty-five percent of the patients with primary carcinomas presented with advanced tumours (T3 or T4). Good local tumor control was obtained as only 25% of the patients with advanced tumours (T3 and T4) and 7% of those with smaller tumours (T1 and T2) had a local relapse after treatment. Recurrent tumours following primary surgery did not respond as well; 50% of these patients still had carcinoma 1 month following therapy. All patients experienced acute toxicity (dermatitis/mucositis, diarrhoea and general fatigue), and 50% needed as split course. There was, however, no therapy-related mortality. Survival data seem promising, but further follow-up is necessary to make conclusions. Eight percent of the patients had serious anal insufficiency after treatment. We conclude that the present regimen provides good local tumour control and well-preserved anal function, but has considerable acute toxicity.

Chemotherapy and radiation therapy for anal carcinoma. Survival and late morbidity

This study was performed to evaluate the survival and late morbidity rates of a widely used combined chemotherapy and radiation therapy regimen given to patients with carcinoma of the anal canal. One hundred six patients received radiation therapy (5000 cGy given by two anteroposterior-posteroanterior [AP-PA] opposed fields) and chemotherapy (mitomycin C plus 5-fluorouracil [5-FU]) from 1983 to 1989. Patients with primary tumors (n = 86) had a complete response rate of 84% and a 5-year survival rate of 72%. There was no significant difference in survival rate according to tumor stage. Patients with local recurrence (n = 20) after primary surgery had a complete response rate of 50% and a 5-year survival rate of 40%. Fifteen percent of the patients experienced late treatment-related symptoms including anal incontinence, intestinal obstruction, and chronic pelvic pain. The current treatment regimen is effective but carries a considerable risk of complications. As survival rate was independent of tumor stage, the locoregional treatment should probably be less extensive for small tumors than for advanced tumors. This strategy may reduce the late side effects for patients with small tumors without reducing the survival rate.

Diagnosis of anal carcinoma--doctor's finger still the best?

Symptoms, delay in diagnosis, tumour stage and the clinical value of a follow-up programme were studied in 107 patients admitted to the Norwegian Radium Hospital for anal canal carcinoma. Sixty percent of the patients had advanced tumours (T3 or T4) at the time of diagnosis, while 1/4 presented with metastases to the pelvic lymph nodes and 5% with distant metastases. The most frequent initial symptoms were anal bleeding and pain (38 and 23%, respectively). About 3/4 of the patients experienced more than 1 month's delay of diagnosis, either because of the patient himself (1/2 of the cases), doctor (1/5 of the cases) or hospital (1/10 of the cases). About 1/3 of the patients had more than 6 months' total delay. The follow-up after treatment (chemoradiotherapy) shows that frequent digital rectal examination is the most important procedure. Some patients may benefit from serum carcino-embryonic antigen measurement, liver ultrasonography or chest X-ray.

[Thyroid carcinoma and the recurrent nerve. Recurrence fall-out, incidence and causal circumstances in a large case-load of patients with thyroid carcinoma]

Impairment of vocal cord function is a threat to patients with thyroid carcinoma; either due to the tumor having infiltrated the larynx or the recurrent nerve, or to accidental damage to the laryngeal nerves during thyroid surgery. We have reviewed 1,245 patients' records which were filed under the diagnosis of thyroid carcinoma at Det Norske Radiumhospital from 1956 to 1978. Pareses of vocal cords were noted in 465 patients (37.3%) during the course of their illness. In 135 patients (10.8%) the pareses were due to infiltration by the tumor, most commonly seen in anaplastic carcinoma. In 267 patients (21.4%) the pareses followed surgery; planned resections of the recurrent nerves were performed in 48 patients (3.9%). Transient pareses with normal vocal cord movements within months were experienced in 137 cases (11%). Permanent paralysis caused accidentally during surgery was seen in 82 patients, representing 6.6% of all patients and 4.7% of the surgically exposed nerves. We stress the need for pre- and postoperative evaluation of vocal cord movement as an aid to future diagnosis and optimal surgical planning.

Primary treatment of carcinoma of the anus by combined radiotherapy and chemotherapy

Twenty-four patients with carcinoma of the anus were treated with a combined regimen of external irradiation (50 Gy) and mitomycin C and 5-fluorouracil. A relatively large number of patients with locally advanced disease were included. A local complete response rate of 87.5% was obtained. The major acute toxicity was dermatitis/mucositis, necessitating a split course in 14 cases. After treatment four patients had persistent anal incontinence. After an observation period of 40-70 months 14 of the patients were alive without disease. We conclude that the conservative combined radiotherapy/chemotherapy regimen is an effective treatment also of advanced anal carcinoma, with tolerable toxicity and with promising survival results.