Small-cell lung carcinoma: an analysis of 194 consecutive patients

The treatment of small-cell lung carcinoma (SCLC) requires the careful combination of chemotherapy and radiation therapy. To understand the factors involved in the outcome of these patients, the authors undertook a study of patients treated for limited stage SCLC. The charts of 194 consecutive patients treated at our facilities between 1986 and 1994 were reviewed. All patients underwent thoracic radiation therapy (TRT), 50% received prophylactic cranial irradiation (PCI), and all but one received chemotherapy. The probability of survival at 5 years was 14%, and the disease-free survival (DFS) was 17%. Patients receiving a combination of platinum and etoposide (PE) and Cytoxan (Bristol-Myers, Evansville, IN, U.S.A.), Adriamycin (Adria Laboratories, Dublin, OH, U.S.A.), and Vincristine (Eli Lilly, Indianapolis, IN, U.S.A.) (CAV) experienced a DFS at 3 years of 31%, versus 14% for CAV only and 18% for PE only (p = 0.004). In a multivariate survival analysis, only PCI (p = 0.001), having received PE and CAV (p = 0.01), and response to treatment (p = 0.001) were significant. Radiation dose and field size did not influence outcome. The combination of PE and CAV chemotherapy produced the best results in our series. Unanswered questions regarding the optimal TRT dose, field size, and timing of TRT await the results of ongoing randomized trials.

A phase I study of weekly cisplatin and whole abdominal radiation for the treatment of stage III and IV endometrial carcinoma: a Gynecologic Oncology Group pilot study

A Gynecologic Oncology Group Phase I study was designed to evaluate the toxicity of whole abdominal radiation therapy with concurrent weekly cisplatin in patients with surgical International Federation of Gynaecology and Obstetrics (FIGO) Stage III and IV endometrial carcinoma. Cisplatin 15 mg/m2 was given once weekly during radiation therapy to the whole abdomen with a pelvic boost and optional para-aortic radiation. All eight patients received the prescribed dose of radiation therapy. Cisplatin chemotherapy was halted in one patient due to increased serum creatinine after three cycles. Acute adverse effects were within acceptable limits, with one patient admitted to the hospital after completion of treatment for diarrhea. Hematopoietic toxicity was clinically unimportant. Serious late toxicities included one radiation enteritis requiring a bowel resection and chylous ascites in one patient. There was no late renal damage reported. This regimen appears to be tolerated acutely and the late toxicities were similar to those seen with whole abdominal radiation therapy alone.

Potential underdosing with the use of electron beam therapy in patients with cervical adenopathy and advanced head and neck cancer

To define the adequacy of electron beam therapy in the treatment of N1-N3 head and neck cancer, 24 patients with primary head and neck cancers and N1-N3 cervical adenopathy received primary radiation therapy with or without chemotherapy for definitive control of their disease. All patients underwent computerized tomography (CT) to assist in the design of treatment to the posterior neck with electron beams after photon therapy to the level of spinal cord tolerance. Treatment with electrons to the posterior neck in patients with N1 disease was adequate in 92% (11/12) of patients. However, in patients with N2 and N3 disease, electron beam treatment failed, because of spinal cord tolerance problems, to cover the disease adequately in 92% (11/12). It is concluded that CT should be employed routinely in patients with N1-N3 neck disease to determine the proper electron energy prescription. For some patients, electron beam may not be appropriate, making it necessary to use individual planning to treat adequately the neck disease and avoid the spinal cord.

Potential underdosing with the use of electron-beam therapy in patients with cervical adenopathy and advanced head and neck cancer

To define the adequacy of electron-beam therapy in the treatment of N1-N3 head and neck cancer, 24 patients with primary head and neck cancers and N1-N3 cervical adenopathy received primary radiation therapy with or without chemotherapy for definitive control of their disease. All patients underwent computerized tomography (CT) to assist in the design of treatment to the posterior neck with electron beams after photon therapy to the level of spinal cord tolerance. Treatment with electrons to the posterior neck in patients with N1 disease was adequate in 92% (11/12) of patients. However, in patients with N2/N3 disease, electron beam failed, because of spinal-cord tolerance problems, to adequately cover disease in 92% (11/12). It is concluded that CT should be routinely employed in patients with N1-N3 neck disease to determine the proper electron-energy prescription. For some patients, electron beam may not be appropriate, making it necessary to use individual planning to treat adequately the neck disease and avoid the spinal cord.

Preoperative radiation therapy in clinical stage II endometrial carcinoma

From 1980 to 1987, 30 patients with FIGO clinical Stage II carcinoma of the endometrium were treated with 5000 cGy preoperative pelvic radiation therapy at Thomas Jefferson University Hospital. Patients with gross cervical disease received additional intracavitary irradiation with a tandem and ovoids for a combined total dose of 7000 cGy to point A. All patients then underwent exploratory laparotomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy (TAH/BSO). The 5-year actuarial survival for the entire group was 69%. The 5-year actuarial survival for the 8 patients with papillary serous, clear cell, and undifferentiated small cell carcinoma was 38%, with most patients failing in the upper abdomen. The 5-year actuarial survival for the remaining 22 patients was 82%. The only local failure occurred in the patient with an undifferentiated small cell carcinoma. Although preoperative pelvic radiation therapy together with TAH/BSO appears to offer excellent local control in all patients with Stage II endometrial carcinoma, additional treatment options should be considered for patients with papillary serous and clear cell histologies because of the poor survival and high failure rate in the upper abdomen.

Vertex field verification in the treatment of central nervous system neoplasms

Increasing sophistication of computerized brain tumor treatment plans has enabled clinicians to devise increasingly complex field combinations to spare as much normal brain tissue as possible. These treatment plans often call for the use of a vertex field. This report describes a simple, useful technique for the verification of the vertex (or any non-coplanar) field on the treatment machine--a procedure that is impossible with conventional port film techniques.

Endometrial cancer with para-aortic adenopathy: patterns of failure and opportunities for cure

PURPOSE

To examine the outcome of patients with advanced endometrial cancer whose para-aortic involvement was diagnosed pathologically or lymphographically.

METHODS AND MATERIALS

Fifty patients from four institutions were treated between 1959 and 1990 with preoperative, post-operative, and primary radiotherapy. Para-aortic disease was diagnosed pathologically in 26 patients and lymphographically in the remaining 24 patients. Pathologically diagnosed patients underwent debulking of grossly involved nodes. All patients received external beam treatment through pelvic and para-aortic portals. Median prescribed dose to the pelvic and para-aortic fields was 50 and 47 Gy, respectively. Those treated with primary or pre-operative irradiation also received intrauterine brachytherapy.

RESULTS

The actuarial 5-year disease-free survival was 46% for all patients. Para-aortic failure was significantly decreased among patients undergoing lymph node resection (13% versus 39%, respectively). Relapse-free survival and pelvic control tended to improve among patients receiving surgery plus irradiation in comparison to those treated by irradiation alone. Distant metastases were most common among patients with high grade lesions.

CONCLUSIONS

Long-term disease-free survival is achievable in endometrial cancer patients with para-aortic lymphadenopathy who are treated with extended-field radiotherapy. Cure is mot attainable among patients with well differentiated, early clinical stage disease who receive combined modality treatment. Survival and local failure are similar for radiologically and pathologically diagnosed patients; however, para-aortic failure as a component of local failure was increased in patients who did not undergo surgical debulking of the adenopathy.

Combined pre- and postoperative adjuvant radiation therapy for bladder cancer--a ten year experience

From 1978 through 1987, 78 patients with carcinoma of the bladder were treated with combined pre- and postoperative adjuvant radiation therapy. All were given a single dose of pre-operative radiation therapy, 500 cGy, either on the day of or the day before cystectomy. Histological staging on the cystectomy specimens according to the TNM classification system was performed. Forty patients with Stage P2 (high grade III and IV), P3A, P3B, P4A, or N+ underwent planned high dose postoperative radiation therapy (4000-4500 cGy) in 5 weeks. The whole pelvis was treated with conventional fractionation of 180 cGy 5 days per week. Median follow-up was 52 months, with 36 months minimum follow-up. There was a 67% overall 5-year survival, and those with P1 and P2 (Grade I and II) had an 84% 5-year survival. Survival for patients with P2 tumor (Grade III and IV), P3A, P3B, and P4/N+ stages was 57%, 56%, 39%, and 50%, respectively. Bowel obstructions developed in 8% of patients who received no postoperative radiation therapy and 37% in those who did. Genitourinary complication rates were similar in both groups, 13% in the group that received no postoperative radiation therapy and 10% in the group that did. Although the planned approach of combined pre- and postoperative radiation therapy for unfavorable stages of bladder cancer is associated with a better than 50% 5-year survival rate (except in Stage P3B cancer), the bowel toxicity was unacceptably high.

Survival and failure analysis in stage II endometrial cancer using the revised 1988 FIGO staging system

Fifty-one patients with Stage II endometrial carcinoma diagnosed between 1974 and 1987 were restaged according to the FIGO 1988 revisions for endometrial carcinoma. Patients were divided into Stage IIA, those patients with cervical glandular involvement without stromal invasion, and Stage IIB, those patients having stromal invasion of the cervix. Tumor grade was also assessed. Patients were treated with radiation therapy alone, pre-operative radiation therapy followed by a simple hysterectomy, or a simple hysterectomy followed by postoperative radiation therapy. The 5-year actuarial survival for Stage IIA was 86% and the 5-year actuarial survival for Stage IIB was 46% (p = 0.06). The 5-year local recurrence rate in each group was 9%. Stage IIA had a distant metastases rate of 14% whereas 44% of the patients in Stage IIB developed distant disease (p = 0.06) at 5 years. The grade of the tumor did not play a role in local recurrence. However, when tumor grade was analyzed with respect to distant disease, 14% of patients with grade 1 tumors developed distant metastases, 31% of patients with grade 2 tumors developed distant metastases, and most significantly, 63% of patients with grade 3 tumors developed distant metastases (p = 0.004). There was no statistically significant relationship between stromal invasion and tumor grade. This study concludes that grade is the greatest predictor of survival, with only 37% of grade 3 patients surviving at 5 years. As a predictor of survival, stromal invasion is of less significance than grade (p = 0.06 vs. p = 0.004). Death most often occurs because of distant metastases, and local failure is rare and is not dependent on the degree of cervical involvement or grade.

Stage IB glassy cell carcinoma of the cervix diagnosed during pregnancy and recurring in a transposed ovary

A case report of glassy cell carcinoma of the cervix occurring during pregnancy is presented. Clinical staging was FIGO IB and treatment consisted of a radical hysterectomy, bilateral ovarian transposition, and postoperative pelvic radiation therapy. The patient had a relapse in one of the transposed ovaries. A review of ovarian conservation in Stage IB carcinoma of the cervix is discussed.