Multiple teams, multiple projects, multiple groups at the intersection of (multiple) research fields: A bibliometric study

Multi-teaming is a concept studied across a variety of disciplines. While using a bibliometric approach on 255 research papers extracted from Web of Science, we aimed to depict the architecture of the multi-teaming concept across academic disciplines and time. Results of citation, co-citation and bibliographic coupling analyses identified four major fields looking at the concept of multi-teaming. The fields emerged over time from fragmentation to integration and acknowledging similarities. We identify gaps and propose (multi)-disciplinary research ideas that can benefit the field of multi-teaming.

Paradoxical Virtual Leadership: Reconsidering Virtuality Through a Paradox Lens

This conceptual article moves the conversation about virtual leadership forward by blending extant knowledge on virtuality and on leadership. Drawing on paradox theory, we show that virtuality is a paradox; therefore, virtual leadership’s core function is to deal with paradox. Our paradoxical virtual leadership model introduces three distinct leadership styles: synergistic, selective, and stagnant. Synergistic leaders view virtuality through a both–and cognitive framework, integrate divergent forces into synergistic solutions, and engage in varied, even opposing, behaviors to synergize virtuality’s paradoxical tensions and leverage the power of paradox. In contrast, selective leaders view virtuality through an either–or framework, and attempt to either manage virtuality’s challenges, or to capitalize on its opportunities, thus failing to balance paradoxical tensions. Finally, stagnant leaders adopt an avoidant framework, ignoring or avoiding virtuality’s paradoxes, and fail to lead effective virtual teams. The practical implications of this model—especially as they relate to how virtual leaders can synergize paradoxical tensions—are discussed.

Diagnostic and Prognostic Value of Lymphography in Patients with Cancer of the Endometrium

The results of foot lymphography in 161 patients with endometrial carcinoma, observed from 1968 to 1977 at the Istituto Nazionale Tumori of Milan are reported. Ninety-three were new cases, 40 were recurrences, and 28 were patients who underwent restaging diagnostic procedures without clinical evidence of disease. The majority of the cases were adenocarcinomas (146/161, or 91%), 10 were mixed adenosquamous carcinomas (6%) and 5 (3%) were adenoacanthomas. The overall incidence of pathologic lymphograms was 30% (46/161 patients). The incidence of the lymphatic spread was related to the clinical stage and to the extent of recurrent disease. In fact, in the 93 new cases, lymphography was positive in 11% of patients at stage I, 39% at stage II, 57% at stage III and 67% at stage IV disease. In the 40 pretreated patients, lymph node involvement was 33% in vaginal recurrences, 52% in pelvic abdominal recurrences and 73% in widespread diffusion. Finally, in 28 pretreated patients with no evidence of disease, the incidence of lymph node involvement was 7%. Metastases were found only in the pelvic nodes in 59% of the patients and only in the para-aortic nodes in 10%; in 31%, both chains were simultaneously involved; bilateral involvement was found in 45% of the patients with radiologically proven metastases. The 5-yr survival rate for patients at stage I-II and III disease with positive lymphography was 47.6% as compared with 83.5% for negative cases. In patients at stage I and II, the difference of survival was equal to 23.4%. The reliability of the results is confirmed by the concordance with the data of the literature on histologic involvement, by the first radiologic-anatomic comparison, and by the clinical course of the positive cases. Lymphography is of unquestionable value for an appropriate staging and for a correct treatment. The prognostic significance of the procedure is evident and such as to justify a major therapeutic aggressiveness in positive cases.

Radio-Chemotherapy of Anal Cancer

Conventional treatment of anal cancer has been the demolitive Miles operation for decades. Radiotherapy has been utilized in a limited number of centers for early cancers only. Radio-chemotherapy has become the treatment of choice for all stages of anal cancer after the first experiences by the group of Detroit and after the confirmation of successful results by many other centers. Infusional chemotherapy (5-FU and Mitomycin C or CDDP) and concurrent irradiation are able to achieve local control in more than 80% of patients. Surgery currently represents a rescue treatment for partial responders or in relapsing patients. A brief review of the literature and the experience at the Istituto Tumori in Milano are presented.

Adult Granulosa Cell Tumor of the Ovary: A Clinico Pathologic Study of 35 Cases

Aims and background

Adult granulosa cell tumor has a low malignant potential but requires an extensive follow-up of more than 5 years to accurately assess tumor activity. The aim of the present study was to evaluate the clinical characteristics, the treatment and the outcome of this rare ovarian tumor.

Study design

A retrospective review of 35 cases treated at primary onset of disease during a 23-year period from 1971 to 1993.

Results

The disease-free survival rate for stages IA-B-C at 5 and 10 years was 90% and 84%, respectively; for stages III-IV the 5-year freedom from progression rate was 16%.

Conclusions

The most important prognostic factor appears to be the extent of tumor involvement outside of the ovary.

Small Size T4 Breast Cancer. Natural History and Prognosis

The clinical records of 66 patients with a 14 (for skin infiltration or ulceration) breast cancer not larger than 5 cm treated with primary radiotherapy at the Istituto Nazionale Tumori of Milan from 1968 through 1977 were reviewed. The tumor measured no more than 3 cm in 19 patients and 3-5 cm in 47 patients. In the first group axillary involvement was lower (32 % vs 55 %) and mean age was older (68 years vs 58). Thirty-four patients were irradiated with orthovoltage and 32 with cobalt, at full doses. In 22 of 66 patients (33.3 %) a Halsted radical mastectomy was carried out after completion of radiotherapy. No medical treatment was planned. The incidence of locoregional and distant metastases was the same in both groups of patients, but that of patients with smaller T4 (up to 3 cm) demonstrated a better prognosis in terms of absolute survival at 5 years (71.3 % vs 34.7 %). T4 breast cancer of 3-5 cm had very poor results quite similar to those of historical large series of T4 carcinomas of any size; therefore they should be treated by the same aggressive combined modality approach adopted for locally advanced breast cancer. On the contrary, small T4, up to 3 cm, in older women could be treated by tumorectomy followed by radiotherapy at full doses; systemic medical therapy (hormonal manipulation or chemotherapy) should be decided according to endocrine receptor investigation and general conditions.

Bronchial Involvement by Hodgkin Disease

Two cases of Hodgkin disease, lymphocyte depletion type, with bronchial involvement are described. One patient revealed involvement of the right upper lobar bronchus, the other patient of the left main bronchus. The correct diagnosis was made by fiberbronchoscope examination with cytologic brushing and biopsy. That bronchial involvement by Hodgkin disease is very rare is confirmed by the literature, where only 20 cases have been so far reported.

A Clinical and Pathologic Study of 34 Sarcomas of the Uterus

The clinical and pathologic features of 34 uterine sarcomas were studied to determine the natural history of the disease. Sixteen patients had leiomyosarcoma, five mixed mesodermal sarcoma, ten endometrial stromal sarcoma, two carcinosarcoma and one endolymphatic stromal myosis. The patients were treated without an unique protocol. At 3 years the actuarial relapse-free survival was 53.6 %: 68.4 % in stage I-II patients and 22.2 % in stage III-IV patients. As regards the histologic subtype mixed mesodermal sarcomas had the best prognosis; endometrial stromal sarcomas the worst. The necessity of a uniform clinical and histologic classification as well as the importance of controlled clinical trials are pointed out.

Tumorectomy plus Radiotherapy in the Management of Breast Cancer

From 1974 to 1982 a total of 58 patients with locoregional breast cancer, judged not suitable for demolitive surgery because of old age, bad general conditions or other reasons, were treated with simple tumorectomy followed by radiotherapy. The median age of the patients was 71 years. Two patients had synchronous bilateral breast cancer, both treated with the same conservative approach. Thirty-three tumors were classified as T1, 24 as T2, 1 as T3, and 2 as T4 of a small size. The median size of the tumor was 2 cm; mean size was 2.24 cm. Radiotherapy was given to the whole breast, followed by a conedown on the tumor bed. The median dose to the tumor bed was 64 Gy, over 7-9 weeks. Thirty-two patients received irradiation on nodal sites too, up to 45-60 Gy. The median follow-up for the whole series was 44 months. Only 4 of 60 treated breasts have presented a local recurrence (6.6%); relapse-free survival at 3 and 5 years is 85.4% and 79%, respectively. Our results confirm that tumorectomy followed by radiotherapy appears to be a very effective alternative to radiotherapy alone and to demolitive surgery. In fact, local control, survival and cosmetic results are quite satisfactory and achievable through a simple therapeutic modality.

Radiotherapy Alone and Radiotherapy Followed by Radical Mastectomy in T2 Breast Cancer

Ninety-four patients with T2 NO, N1a, N1b, MO were treated with primary radiotherapy (RT) because of old age or poor general conditions. In 32 patients (34 %), younger in age and in better general conditions, Halsted radical mastectomy could be performed 5–8 months from starting RT; surgery was not done at random, but decided case by case on the basis of a good response to RT and an improvement of general status. Relapse was documented in 42 patients. Relapse rate was 50 % in the group treated with RT alone (high incidence of breast recurrences) and 33 % in the group operated on after RT. Distant metastases had the same incidence in the 2 groups, with a median free interval of 14 months. Overall disease-free survival rates at 5 to 10 years were 46 % and 35 %, respectively; these results are not particularly different from the data of historical series of T2 breast cancer treated with surgery alone. The patients operated on after RT had a significantly better survival, but the results were clearly influenced by the selection of patients. For the future, a safe policy could be a conservative combined treatment consisting of tumorectomy followed by curative RT; adjuvant medical therapy could be scheduled for high-risk patients (N1b).

Cobalt Therapy in the Treatment of Carcinoma of the Oropharynx

A clinical retrospective evaluation of 177 cases of carcinoma of the oropharynx treated with Cobalt therapy from 1959 to 1965 has been made. The analysis of long term results has shown that Cobalt therapy alone does not satisfactorily control carcinomas of oropharynx. In fact, less than 30% of the patients is still alive after 3 years. Survival is directly affected by the local extent of disease since, while the 5-year survival of Tl and T2 cases is respectively 26.8% and 21.5%, only 6.5% of patients with T3 carcinomas is still alive after 5 years. Particularly disappointing is the survival rate in cases with mono- or bilateral involvement of neck nodes, since none of these cases are alive 2 years after the initial therapy. In 69.4% of the cases, treatment failure has to be attributed to minimal response or early recurrence of primary tumor, while lymph node relapses have been observed in more than 25% of the cases. To allow a detailed clinical evaluation of the results, the different regions of the oropharynx should be considered separatly, since differences in clinical evolution of various carcinomas would call for a different therapeutic approach. The results of this study in oropharyngeal carcinomas, indicate that improvement of long term results may only be obtained through a multidisciplinary therapeutic approach.

A Retrospective Analysis of 53 Patients with Pathologic Stage II and III Endometrial Carcinoma

From 1969 to 1977, 53 patients with surgical-pathologic stages II and III endometrial carcinoma were seen at the Istituto Nazionale Tumori of Milan. The treatment was individualized. The 5-year survival was 68.8% in stage II and 75.3% in stage III. The relapse-free survival was 68.9% and 69.4%, respectively. Adjuvant type of radiotherapy, degree of differentiation, depth of myometrial invasion, and especially sites of disease were the factors influencing survival.

Chlamydial infection of the urinary tract in children and adolescents with hematuria

Urogenital infection with Chlamydia trachomatis in adults and adolescents is a common sexually transmitted disease. The purpose of this study was to investigate whether isolated microhematuria in children and adolescents is associated with Chlamydia trachomatis infection of the urinary tract. The study group included 37 children and adolescents with isolated nonglomerular microhematuria. Urethral smears for the isolation of Chlamydia trachomatis in cell culture were taken at the time of cystourethroscopy from all patients. Polymerase chain reaction (PCR) for the detection of chlamydial DNA in urine was carried out in 25 of 37 (68%) patients and direct immunofluorescence (DIF) of urine in 16 of 37 (43%) patients. The control group included 33 children and adolescents without hematuria; PCR and DIF of urine were carried out in all controls. Chlamydia trachomatis infection of the urinary tract was confirmed in 8 of 37 (22%) patients in the study group, and in none in the control group (0 of 33, P<0.001). Further studies of larger groups of patients should be conducted, before recommending testing for Chlamydia trachomatis infection of the urinary tract in children and adolescents with unexplained microhematuria.

Early breast cancer: evaluation of the prognostic role of the site of the primary tumor

PURPOSE

The prognostic role of the site of the primary breast cancer has not been clarified. This study aimed to gather more information about this issue from a large series of patients with long-term follow-up data.

PATIENTS AND METHODS

Data from 2,396 patients treated for early breast cancer with a conservative approach were reviewed (1973 to 1989). In 1,619 patients, the tumor had a lateral site, while in 777 cases, it was situated in the internal/central quadrants. The characteristics of the two groups were well balanced, apart from axillary nodal metastases, which were more frequent for lateral tumors (38.1% v 26.3%).

RESULTS

Analysis of distant metastases indicated that the regression coefficient associated with tumor site was significant and the hazards ratio estimate was 1.291, which indicates the risk of distant metastases was increased by approximately 30% for internal/central tumors. The analysis of overall survival yielded a significant coefficient and a hazards ratio of 1.192, which indicates an approximately 20% increase of mortality for internal/central tumors.

CONCLUSION

Early breast cancers situated in central/ internal quadrants have a worse prognosis compared with those in lateral quadrants, in terms of distant metastases and survival. Irradiation of the internal mammary chain for internal/medial tumors could be suggested, but, to date, the therapeutic strategy is still controversial.

Radio-Chemotherapy of Vulvar Cancer

Surgery alone, more or less demolitive, is the treatment of choice of vulvar cancers. Cure rates are high for early cancers only, while locally advanced tumors with or without inguinal adenopathies and recurrences have a bad prognosis. The excellent results of concurrent chemo-radiotherapy of anal cancers suggested to adopt the same approach for locally advanced vulvar cancers. The shrinkage of the tumor allowed surgery, often less demolitive than usual, and the pathological examination demonstrated an overall complete response in 40% of cases. Survival has been improved through this multidisciplinary approach. Patients not suitable for surgery obtained important remissions and an improved quality of life. Clinical experience at the Istituto Tumori of Milano is presented.

Analysis of risk factors for mandibular bone radionecrosis after exclusive low dose-rate brachytherapy for oral cancer

BACKGROUND

Brachytherapy is widely adopted as an exclusive treatment of T1/T2 oral cancer with a high probability of definitive cure. Therefore, any major complication, like mandibular bone necrosis, should be avoided. Many risk factors, either clinical or technical, have been considered in the literature.

MATERIALS AND METHODS

One hundred consecutive interstitial iridium LDR treatments for early cancers of the tongue and floor of the mouth performed from January 1989 to November 1993 were reviewed. An analysis of some simple technical parameters (total dose, dose-rate, reference volume, linear activity, total reference kerma) was performed in order to identify the main physical risk factors. Moreover, total dose was recalculated as extrapolated responsive dose for normal tissue complications.

RESULTS

Bone necrosis was observed in 10 out of 100 patients with a median follow-up of 38 months. No significant incidence of this complication was observed when tumor site (mobile tongue versus floor of the mouth), dental status or total physical dose were considered. A significant correlation between the incidence of bone necrosis and two main parameters was found, i.e. dose-rate (P < 0.02) and reference volume (P < 0.05).

CONCLUSIONS

A threshold value may be suggested both for dose-rate (50 cGy/h) and reference volume (25,000 mm3). Bone necrosis is clearly related to both these parameters since most cases (i.e. 80%) were observed in the subgroup over the volume and dose-rate threshold.

Expression of p53, glutathione S-transferase-pi, and Bcl-2 proteins and benefit from adjuvant radiotherapy in breast cancer

BACKGROUND

In clinical breast cancer research, the utility of certain biomarkers as predictors of response to surgery, chemotherapy, or hormonal therapy has been studied intensively. Much less research has been done on the relevance of biologic predictors of response to radiotherapy, which represents an effective local-regional treatment for breast cancer.

PURPOSE

The utility of biomarkers involved in DNA damage repair (p53 protein), control of programmed cell death (p53 and Bcl-2 proteins), and cellular detoxification (glutathione S-transferase-pi [GST-pi] enzyme) in predicting local breast cancer recurrence was analyzed retrospectively in two cohorts of breast cancer patients. These patients had had no detectable metastases in the axillary lymph nodes (i.e., node-negative) or in distant sites and had had similar distributions of clinicopathologic and biologic prognostic features. They had been treated by conservative surgery alone (139 case patients) or by conservative surgery followed by adjuvant radiotherapy (496 case patients) during the period from 1984 through 1990.

METHODS

The expression of the p53, GST-pi, and Bcl-2 proteins in the specimens of primary breast tumor obtained from these patients was determined by use of immunohistochemistry; cell proliferation activity and levels of steroid receptors were determined by use of a [3H]thymidine-labeling index assay and the dextran-coated charcoal technique, respectively. The median time of follow-up of patients was 6 years. In the analyses of patient outcomes, only local failures that presented as first events were considered.

RESULTS

After surgery alone, the risk of local recurrence at 6 years was higher for patients with tumors exhibiting elevated levels of p53 and GST-pi protein expression than for patients with low levels (hazard ratio [HR] = 3.1, 95% confidence interval [CI] = 1.3-7.7, two-sided P = .012; HR = 2.7, 95% CI = 1.1-6.4, two-sided P = .026, respectively). Weak or no observable expression of Bcl-2 protein was only suggestive of a higher frequency of local failures. Adjustment for patient age, tumor size, cell proliferation, and estrogen receptor status did not change these findings. Conversely, in the series of patients given conservative surgery followed by radiotherapy, there was no difference in local tumor recurrence between patients with tumors expressing or not expressing each of the three markers.

CONCLUSIONS

Our study provides indirect evidence of a benefit from radiation therapy in preventing local breast cancer relapse, particularly among node-negative patients with tumors that express elevated levels of the p53 or GST-pi proteins or that express little or no Bcl-2 protein.

Current controversies in the therapeutic approach to early breast cancer in the elderly

Over a 7-year period, in 408 patients aged 70 years or more, 413 early breast cancers were treated as follows: quadrantectomy, axillary dissection, and radiotherapy (QUART) in 142 patients, wide lumpectomy plus radiotherapy extended to the axilla in case of palpable nodes (WLRT) in 45 patients and wide lumpectomy alone in 221 patients. Postoperative tamoxifen was given to 251 patients and chemotherapy to 31. Mean follow-up was 54 months. Relapse free survival was similar at 5 years in the three groups (80%); at 10 years it was 80.8% in QUART, 61.3% in WLRT, 51.7% in WL. Locoregional recurrence, as first failure, occurred in 1.4% QUART, 6.5% WLRT and 15.2% WL. In our experience compliance with surgical day-hospital regimen was excellent, while postoperative radiotherapy created some problems, mainly among oldest patients. We support the role of radiotherapy for its positive impact on local control.

Primary chemoradiation therapy with fluorouracil and cisplatin for cancer of the anus: results in 35 consecutive patients

PURPOSE

This prospective phase II study was designed to test the activity and toxicity of a regimen of fluorouracil (5-FU) and cisplatin (CDDP) in combination with radiation therapy in the treatment of epidermoid cancer of the anal canal.

PATIENTS AND METHODS

Thirty-five consecutive patients with untreated epidermoid cancer of the anal canal were candidates for chemoradiation therapy (CRT). Staging of cancer was as follows: T1, 26%; T2, 60%; T3, 14%; and N1, 2,3, 26%. No patient had distant metastases. The treatment protocol consisted of two to three cycles of chemotherapy starting on days 1 and 21 and concurrent radiotherapy at a daily dose of 1.8 Gy up to a total dose of 36 to 38 Gy in 4 weeks, delivered to the anal region, perineum, middle and lower pelvis, and inguinal and external iliac nodes. Radiotherapy was then delivered to the anoperineal region and metastatic inguinal nodes to a total dose of 18 to 24 Gy in 10 fractions. Chemotherapy consisted of 24-hour intravenous (IV) infusion of 5-FU 750 mg/m2 on days 1 to 4 and CDDP 100 mg/m2 by 60-minute IV infusion on day 1.

RESULTS

All patients received two cycles of chemotherapy; the second was delayed in three patients because of leukopenia that was evident in 11 (31%). In eight patients, a third cycle was added. They all experienced nausea or vomiting; one patient showed signs of cardiotoxicity and one developed proctitis, dermatitis, and diarrhea (grade 3). Complete regression (CR) was assessed in 33 patients (94%); nine patients with metastatic lymph nodes also had CR. Two patients had a partial response (PR); both underwent abdominoperineal resection, which was not curative in one. Two patients (6%) had a local recurrence; in one, this was associated with hepatic metastases. One of these patients underwent surgery and is alive after about 4 years, while the other is undergoing chemotherapy. After a median follow-up duration of 37 months, 94% of patients are alive without evidence of disease and 86% are colostomy-free.

CONCLUSION

This regimen is well tolerated; its toxicity does not exceed that observed with the combination of 5-FU and mitomycin (MMC). Compared with our previous experience based on the classic CRT (5-FU, MMC, and radiation), the objective response rate observed with this new combination was similar. However, the local recurrence rate, observed in patients treated with the new regimen, was lower (6% v 24%). According to more recent data from the literature, primary CRT is the elective indication in epidermoid cancer of the anus and replacement of MMC with CDDP seems an effective and logical evolution.

Combined preoperative chemoradiotherapy followed by radical surgery in locally advanced vulvar carcinoma. A pilot study

BACKGROUND

Although for decades exenterative surgery has represented the standard treatment for patients with locally advanced vulvar cancer, combined approaches, including preoperative radiation with or without chemotherapy, are now considered the treatment of choice. We report the results of a pilot study on concurrent chemoradiotheraphy followed by radical surgery for patients with locally advanced squamous cell carcinomas of the vulva.

METHODS

Thirty-one patients with squamous cell carcinoma of the vulva were treated with two courses of combination chemotherapy mitomycin C, 15 mg/m2 intravenously (i.v.) on Day 1, and 5-fluorouracil, 750 mg/m2 i.v., in continuous 24-hour infusion on Days 1 to 5. Inguinal and pelvic lymph node chains and the vulva were irradiated (starting on the same day as the chemotherapy) up to a total dose of 36 Gy. After a 2-week interval, a second course of chemoradiotherapy was given (18 Gy on the vulvar region only). After 2 weeks, patients underwent radical surgery.

RESULTS

An objective response was observed in 22 of 24 primary cases (91.6%) and in 7 of 7 recurrent cases. All but two unresponsive patients underwent radical surgery. The postoperative morbidity rate was 65% (19 of 29 patients), and the mortality rate was 13.8% (4 of 29 patients). Five of nine patients (55%) with biopsy-proven inguinal lymph node metastases showed no residual lymph node disease in the surgical specimen. The recurrence rate was 31.8% and the medial follow-up time was 34 months.

CONCLUSIONS

Chemoradiotherapy seems to be effective for squamous cell carcinoma of the vulva. If treatment-related morbidity could be decreased, such a combined approach might offer a new perspectives for a conservative treatment of locally advanced vulvar cancer.

[Ileal obstruction following radiosurgical treatment for rectosigmoid neoplasm]

A series of 191 patients submitted to adjuvant radiotherapy after surgery for rectal and rectosigmoid carcinoma from January, 1975, to December, 1990, has been analyzed to evaluate the incidence of high grade small bowel late toxicity (grades III/IV according to RTOG/EORTC scoring system). Surgical approach was abdominoperineal Miles resection in 92 patients, while a sphincter preserving bowel resection was performed in 99. The total radiation dose to the pelvis ranged from 40 to 60 Gy in 4 to 8 weeks, with conventional fractionation. Three different beams arrangements were used: two sagittal parallel opposite AP-PA fields in 106 patients, three fields (one posterior sagittal plus two parallel lateral fields) in 56, four fields (box technique) in 29. Fourteen patients (7.3%) developed sequelae grades III/IV: three of them died of toxicity. Average free interval between radiation and complication was 23 months (range: 4-87). The following risk factors were investigated: sex, age, type of surgery on primary rectosigmoid cancer, previous abdominal or pelvic surgery, radiation technique, treated volume, administered radiation dose. Dose was calculated as BED (time corrected biologically equivalent dose) according to the linear quadratic model. The only factors significantly related to late intestinal complications were the beam arrangement and, consequently, the treated volume. Detailed analysis showed that radiation sequelae developed in 12/106 (11.3%) patients treated with the two sagittal fields technique, while small bowel toxicity was observed in only 2/85 (2.3%) patients treated with the three--or four--fields technique. The difference is stastically significant (p < 0.05). Another significant correlation was the ratio between treated volume and late complications incidence observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Nondysgerminomatous tumors of the ovary treated with cisplatin, vinblastine, and bleomycin: long-term results

Twenty-four consecutive patients with nondysgerminomatous germ cell tumor of the ovary were treated after surgery with cisplatin, vinblastine, and bleomycin (PVB regimen). The cycle was repeated every 3 weeks for three to five courses. Fourteen patients had endodermal sinus tumor, and 10 had mixed germ cell tumors. Stage of disease (FIGO, 1986) was as follows: stage I, 6; stage IIc-IV, 17; and recurrence, 1 patient. All patients were monitored by alpha-fetoprotein and human chorionic gonadotropin. Only 1 patient had received previous chemotherapy. All 5 patients without residual disease and with negative marker levels in which PVB was used as adjuvant treatment were free of disease for a median duration of 59 months from the start of PVB. Of the 19 patients with measurable disease (evident disease or positive marker levels), complete remission was obtained in 16 (84%), but 5 of these relapsed. Therefore, treatment with PVB failed in 8 out of 19 patients (42%) with measurable disease. Toxicity was evident, but no patient died of it. Menses were regular in 11 patients whose initial surgery was conservative. PVB regimen is an effective but not a satisfactory treatment. The considerable failure rate of PVB treatment suggests the investigation of other regimens.

[The results of definitive transcutaneous radiotherapy in the treatment of oropharyngeal neoplasms]

From January 1976 to December 1986, 199 patients with oropharyngeal cancer were submitted to definitive radiotherapy. Survival and local control were analyzed and related to different parameters--i.e, T and N categories, histopathologic grading, tumor location, patients age, and radiation dose. Fifty-six per cent of patients (111/199) died from neoplastic disease within 5 years. Local progression, recurrence or metastases were observed in 149 cases (75%). Ninety-three per cent of first failures (138/149) were related to residual disease or to locoregional relapse while distant metastases occurred in 14 patients only. The majority of locoregional failures (94%) appeared within 2 years, with a mean disease-free interval of 8 months. Tumor recurrence in the primary location was observed to be the first cause of failure in 78% of relapsed patients; moreover, it was the sole cause of failure in half of the unfavorable events. On the contrary, nodal relapse appeared in 38% of treatment failures and in 12% only it was the sole cause of failure. Overall and disease-free survival were observed to depend mainly on T and N categories, while histopathologic grading was seen to affect only early response rate. No significant differences were observed depending on tumor site and patients age. Local control rates depended on total radiation dose, but the difference between low dose (NSD less than 1700) and high dose (NSD greater than 1700) was significant only for T1 and T2 patients.

Renal ultrasound and excretory urography in infants and young children with urinary tract infection

The main purpose of the study was to see whether excretory urography (EU) can be safely replaced by ultrasound (US) in children with urinary tract infection (UTI) younger than 6 years. 101 hospitalised children were admitted to the prospective study. They were all diagnosed as having UTI and were treated accordingly. All children had voiding cystography (VCU), EU and US done. US and EU correlated well in 94% of the cases. In all 6 cases with discrepancy between EU and US, the VCU was abnormal. Our results confirm the data from other authors, that VCU and US should be sufficient as an initial work-up on children with UTI, while EU should be done only in the cases with abnormal findings on either one or both of the former investigations. However, it should be kept in mind that some cases of parenchymal involvement or mild subpelvic stenosis can be missed using this protocol. If EU is obtained only in the cases with abnormal US and/or VCU, only 55 children (54%) in our group would have had an EU done.

Germ cell tumors of the ovary: the experience of the National Cancer Institute of Milan. I. Dysgerminoma

The experience of the Istituto Nazionale Tumori of Milan on dysgerminoma is presented. Between 1970 and December of 1982, 25 patients were treated with a unique protocol which considered surgery and radiotherapy with different schedules according to the extension of the disease. With this treatment protocol all 13 patients at Stage I were alive and free of disease with a median follow-up of 77 months. Of 12 patients at Stage III (10 retroperitoneal and 2 retroperitoneal and peritoneal) 4 relapsed. The 5-year relapse-free survival of Stage III patients was 61.4% and the overall survival 89.5%. Amenorrhea due to radiation dose absorbed by the contralateral shielded ovary was found in 7.7%. The excellent results in Stage I patients were balanced by the unsatisfactory results in Stage III patients. A more aggressive treatment and the knowledge of other prognostic factors seem necessary.

Endometrial carcinoma: stage I. A retrospective analysis of 262 patients

From 1969 to 1977, 420 patients with endometrial carcinoma were observed and treated at the National Tumor Institute of Milan. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed in 351. After careful clinical and pathologic review, 262 patients were classified as having stage I disease. Further treatment included post-operative radium therapy to the vaginal vault. There were 247 cases with adenocarcinoma, 10 with adenoacanthoma, and 5 with adenosquamous or clear cell carcinoma. Of 257 cases with adenocarcinoma or adenoacanthoma, 63 were grade 1, 161 grade 2, and 33 grade 3. Of the total series, only 41 cases had disease limited to the mucosal surface. The 5-year actuarial survival was 91.4% and the recurrence-free survival was 93.4%. The case material was evaluated according to the risk factors, and results were 1) premenopausal patients had a better prognosis (100% recurrence-free survival versus 92.8% for postmenopausal women, P = .003); 2) length of the uterine cavity was not a significant prognostic factor; 3) myometrial invasion alone was not prognostic but correlated with grade of tumor; 4) the grade of the tumor was an important determinant of recurrence (grade 1 98% recurrence-free survival, grade 2 95%, grade 3 79%). With the described therapy, vaginal recurrences were absent. The recurrences were distant in 20% and local with or without distant metastases in 80%.

Natural history of dysgerminoma

Data on 56 patients with pure dysgerminoma are discussed. Forty-nine patients were classified as having new disease or were to have reassessment of disease, and seven cases were to be restaged (one with and six without clinical evidence of disease). Of new and reassessment cases, 44 patients underwent lymphography, 16 underwent peritoneoscopy with diaphragmatic inspection and 30 had peritoneal cytologic testing performed. Positive lymphography resulted in restaging in 31.6% of patients. Diaphragmatic inspection was always negative. Peritoneal cytologic testing was positive for malignant cells in three patients and worsened the stage in one. Pathologic staging of disease was as follows: Stage IA, 24; Stage IB, one Stage IC, one; Stage III peritoneal disease, two. Stage III retroperitoneal disease, 12; Stage III peritoneal and retroperitoneal disease; four. The 5-year relapse-free survival rates were 91% in patients with pathologic Stages IA, IB, and IC; 74% in those with Stage III retroperitoneal disease, and 24% in patients with Stage III peritoneal disease or peritoneal plus retroperitoneal disease. The results indicate that the prognosis is excellent for patients with Stage I and Stage III retroperitoneal disease whereas peritoneal involvement is associated with a poor prognosis.

Restaging of patients with ovarian carcinoma

Sixty-four patients, 34 with no clinical evidence of disease (NED) and 30 with clinical evidence of disease (ED), were submitted to restaging with peritoneoscopy plus diaphragmatic inspection, peritoneal cytology, and lymphography. Eleven patients (32.2%) in the NED group and 25 (83.3%) in the ED group had positive restaging findings. The 3 diagnostic procedures, in combination, are important in establishing occult disease and therefore in the planning of further treatment.

Are retroperitoneal lymph node metastases a major problem in endometrial adenocarcinoma? Diagnostic and prognostic assessment with lymphography

The results of foot lymphography in 295 patients with endometrial carcinoma observed from 1968 to 1978 at two institutions are reported. One hundred and eighty-two were new cases, 61 were recurrences, and 52 were patients who underwent restaging diagnostic procedures without clinical evidence of disease. The incidence of lymphatic spread was correlated with the clinical stage, the pathologic stage, and the extent of recurrent disease. In fact, in the 182 new cases, at clinical stage, the pathologic stage, lymphography was positive in 8.9% of patients at Stage I, 28.6% at Stage II, 57.1% at Stage III, and 66.6% at Stage IV disease; at pathological stage, lymphography was positive in 8% of patients at Stage I, 14.8% at Stage II, 39.3% at Stage II, and 53.3% at Stage IV disease. There was lymph node involvement in 47.5% of the 61 pretreated patients. Finally, in 52 pretreated patients with no evidence of disease, the incidence of lymph node involvement was 7.7%. In new cases, metastases were found only in the pelvic nodes in 56.2% of the patients and only in the para-aortic nodes in 9.5%; in 34.3%, both chains were simultaneously involved. The five-year survival rate for patients at Stage I, II, and III disease with positive lymphography was 35% as compared with 73% for negative cases. In patients at Stage I and II, the difference of survival was equal to 24%. The reliability of the results is confirmed by the concordance with the data of the literature on histologic involvement, by the first radiologic-pathologic comparison, and by the clinical course of the positive cases. Lymphography is of unquestionable value for an appropriate staging and for a correct plan of treatment.

Retroperitoneal metastases from ovarian carcinoma: reassessment of 365 patients studied with lymphography

From 1973 through 1978, 365 patients with ovarian carcinoma were evaluated with lymphography. The extent of disease was assessed by clinical and conventional radiologic examinations, peritoneoscopy with visualization of diaphragmatic leaves, peritoneal cytology, and, in some patients, exploratory laparotomy. The highest incidence of metastases was found in advanced stages (31.1% in stage III and 60% in stage IV) and in recurrences (75.9%). In 87 patients with early disease, the incidence was 9.2%. In 36 pretreated patients with no evidence of disease, this incidence was 11.1%. Biopsies of the nodes were performed in 96 patients: radiologic accuracy was confirmed in 33 of 33 positive and in 55 of 63 negative cases. Of the patients, 33% had metastases only in the pelvic nodes, and 7.9% only in the paraaortic nodes; in 79.1%, both chains were involved simultaneously. These data confirm the importance of lymphography in diagnosis, treatment planning, and surveillance of ovarian carcinoma.

Second malignancies in Hodgkin's disease: a complication of certain forms of treatment

A total of 764 patients with Hodgkin's disease treated with radiotherapy (RT) or chemotherapy or both were reviewed 3-186 months (median 43 months) after initial treatment to assess the incidence of second malignancies. Incidence of solid tumours and acute non-lymphoblastic leukaemia (ANLL) were calculated by a life-table method and percentages of patients affected derived from life-table plots. Within 10 years after initial treatment the overall incidence of second solid tumours was 7.3%, and over a comparable period 2.4% of patients developed ANLL. Solid tumours occurred only in patients given RT with or without adjuvant chemotherapy, and ANLL occurred only after treatment with MOPP (mustine, vincristine, procarbazine, and prednisolone) or modified MOPP regimens. Neither solid tumours nor ANLL occurred in patients given ABVD (adriamycin, bleomycin, vinblastine, and dacarbazine). The highest incidence of leukaemia (5.4%) occurred after treatment with extensive RT plus (5.4%) occurred after treatment with extensive RT plus MOPP; hence the benefits of this approach in Hodgkin's disease must be weighed against its carcinogenic potential.

Natural history and survival of inoperable breast cancer treated with radiotherapy and radiotherapy followed by radical mastectomy

This retrospective study evaluates the time and site of relapse as well as the median survival of 454 consecutive patients with T3-T4 Nx Mo breast cancer treated with radiation therapy from 1968 to 1972. Radiotherapy was delivered with kilovoltage to the first 221 patients and with cobalt to 233 patients, respectively. A group of 133 selected patients was subjected to radical mastectomy 6-8 weeks after completion of the irradiation. The incidence of first relapse was 45% within the first 18 months from starting radiotherapy. The incidence of relapse was higher in presence than in absence of regional adenopathy, with no statistical difference between T3 and T4. Inflammatory carcinoma showed the highest percent of relapse during the first 12 months (48%). The relapse rate appeared independent from type of irradiation. The site of first relapse occurred more often (68%) in areas distant from irradiation fields. Sterilization of both primary tumor and regional nodes was obtained only in 10% of patients. The median survival for the whole series was 2.5 years, with no significant difference between roentgen therapy (3 years) and cobalt (2.5 years). Unfavorable survival was directly related to the presence of regional adenopathies (2.3 years), especially in the supraclavicular fossa (1.4 years) and of inflammatory carcinoma (1.2 years). Patients treated with radiotherapy followed by surgery showed a median survival of 3.9 years compared to 2.1 years for those given only irradiation. The importance of sequentially combining chemotherapy with radiotherapy is discussed.

Endolymphatic radiotherapy in malignant lymphomas: its potential "prophylactic" value in cases with negative lymphograms

From 1961 to 1969 426 patients (208 with Hodgkin's disease and 218 with non-Hodgkin's lymphoma) underwent endolympatic radiotherapy with Lipiodol 131I at the National Cancer Institute of Milano. For this study, only those patients with stage I, II, or III disease (with or without systemic symptoms), who were not previously treated, and who had a complete follow-up were reviewed. It appears that while in the cases where there is lymphographic evidence of involved lymph nodes, endolymphatic radiotherapy is not of value, in the cases with apparently negative lymphography, endolymphatic radiotherapy can reduce the incidence of relapse in the inguino-retroperitoneal nodes to a statistically significant degree.

Correlations between Clinical Control and Histopathologic Findings in Breast Cancer after Irradiation and Radical Mastectomy

154 cases of breast cancer (30 T1-T2; 124 T3-T4) treated by irradiation followed by radical mastectomy were subjected to histological revision in order to check the efficacy of radiotherapy in the local control of cancer and to seek correlations between the histological findings and the clinical course of the disease. The tumor disappeared completely only in 24 % of cases, the percentage being higher in the initially smaller tumors; the axillary lymph nodes showed disappearance of the metastases in a still smaller proportion of cases, namely 15–20%. Only in 16 cases (10% of cases) were the histological findings negative both at mammary and axillary levels. X-ray therapy and cobalt therapy were of equal value in the local control of the disease, despite the higher doses of cobalt. The patients operated on after radiotherapy had a decidedly better survival rate than those treated with irradiation only, since the former were selected because of their better clinical course and operated on because of this. Of the operated patients those whose axillary histology was negative presented a higher survival rate (75% of patients living) than those whose findings were positive (53%). Factors of negligible importance prognostically were: complete sterilization at mammary and axillary level after radiotherapy, persistence of florid cancer tissue at mammary level and histiocytosis of the axillary lymph nodes. In short, the result of locoregional therapy, even when successful, was not crucial in the general control of the disease, especially in advanced locoregional breast cancer (T3-T4 with axillary metastases).

Radiotherapy of Breast Cancer in the Early Stages (T1-T2)

During the quinquennium 1968–72, 79 patients with breast cancer in the early stages (T1-T2) were given radiotherapy at the National Cancer Institute of Milan after surgery had been excluded on grounds of age, diabetes, cardiocirculatory status or other controindication. 69 patients were at stage T2 and 39 had lymphnode involvement (31 N1 and 8 N3). 40 received roentgentherapy and 39 cobalt therapy. The crude five–year survival was 53 % and the age-corrected rate 62 %, high values considering average age (67 years) and the poor general condition of the patients. Survival was better in the N0 cases that in those with lpmphnode involvement (71 % compared with 50 % at 4 years) and in the over-65s than in the less elderly (77 % against 38 % at 4 years). Cobalt therapy, preferable to roentgentherapy because treatment is less lengthy and is better tolerated, did not yield better clinical results in terms either of local recurrence or of long term survival. Local recurrences occurred in 13 % of patients with a higher incidence at lymphnode level (6/39) that at the primary site. Radiotherapy thus definitely seems to be effective, even on a long term basis, in early breast cancer, when surgery, radical or conservative, is contraindicated.

Lymphomas of Children: Lymphography and Diagnostic Laparotomy in the Planning of Treatment

104 cases of malignant lymphoma in children are considered and the value of lymphography and laparotomy for the purpose of correct staging is demonstrated. 83 patients underwent lymphography and 19 laparotomy. These investigations definitely resulted in significant changes in staging.