Ai-Yih Wang

Primary breast lymphoma: a pooled analysis of prognostic factors and survival in 93 cases.

BACKGROUND Primary breast lymphoma is a rare disease. The small number of patients and the paucity of data make large-series studies difficult. We conducted a pooled analysis to evaluate the treatment outcome and prognostic factors in patients with primary breast lymphoma. METHODS In a search of PUBMED and MEDLINE we found 7 observational studies with 93 patients that were eligible for inclusion. Treatments included single therapy or combined surgery, chemotherapy and radiotherapy. We analyzed the correlation between treatment protocols, tumor relapse and survival. Histopathology and cancer stage were analyzed to evaluate their significance in treatment outcome. RESULTS All 93 patients were female, with a mean age of 57 years. The histopathology of 63 patients (68%) was diffuse large cell lymphoma. According to Ann Arbor classification, 57% were stage I, 23% were stage II, 4% were stage III, and 16% were stage IV. Thirteen percent received surgery alone, 27% received chemotherapy alone, 7% received radiotherapy alone, 10% received surgery and chemotherapy, 10% received surgery and radiotherapy, 22% received chemotherapy and radiotherapy, and 11% received surgery combined with chemotherapy and radiotherapy. With a median follow-up duration of 34 months (mean, 53 months), 48% had relapse of disease, 50% had no relapse, while 2% had disease progression. The mean time to first tumor relapse after treatment was 20 months. The 3-year and 5-year overall survival rates were 70% and 56%, respectively. Radiotherapy was a significant prognostic factor predicting tumor relapse (P=0.044). Tumor stage was a significant prognostic factor affecting overall survival, disease-free survival and disease-specific survival (P=0.0231, 0.0015, 0.0124, respectively). CONCLUSION With a 3-year overall survival rate of 70%, the high relapse rate of 48% is a cause for concern. Patients who received chemotherapy and radiotherapy had better survival outcome and a lower relapse rate. We suggest that chemotherapy and radiotherapy be the initial treatment for patients with primary breast lymphoma.

Prognostic factors affecting the outcome of early cervical cancer treated with radical hysterectomy and post‐operative adjuvant therapy

The purpose of this study is to investigate the clinical and histological features that may affect the survival of the patients and to evaluate the impact of post-operative adjuvant therapy on the outcomes of patients with stage IB and IIA carcinoma of the cervix. From August 1998 to January 2005, 140 patients with International Federation of Gynecology and Obstetrics stage IB and IIA cervical cancer were treated with radical hysterectomy and post-operative pelvic radiation therapy with or without chemotherapy. The median age was 55 years (range, 29-86 years). Seventy-six patients had stage IB and 64 patients had stage IIA disease. Tumour size was <4 cm in 96 patients and > or = 4 cm in 44 patients. One hundred and eleven patients had histology of squamous cell carcinoma, 12 patients has adenocarcinoma and 17 patients had other histologic types. Depth of stromal invasion was <2/3 in 20 patients and > or = 2/3 in 120 patients. Twenty-three patients had parametrial invasion and 117 patients had no parametrial invasion. Thirteen patients had lymphovascular space invasion and 127 had no lymphovascular space invasion. Nine patients had positive surgical margin and 131 patients had negative margin. Twenty-seven patients had pelvic lymph node metastasis and 113 patients had no pelvic lymph node metastasis. Seventy-five patients received concurrent chemoradiotherapy and 65 patients received radiotherapy alone. The 5-year overall survival (OAS) and disease-free survival were 83% and 72% respectively. In the log rank test, tumour size (P = 0.0235), pararmetrial invasion (P = 0.0121), pelvic lymph node metastasis (P < 0.0001) and adjuvant chemotherapy + radiotherapy (P = 0.0119) were significant prognostic factors for OAS, favouring tumour size <4 cm, absence of parametrial invasion and pelvic lymph node metastasis, and those who received adjuvant chemoradiotherapy. The patients who received radiation with concomitant chemotherapy had a 5-year OAS rate of 90% versus those who received radiotherapy alone, with a rate of 76%. For patients with high-risk early stage cervical cancer who underwent a radical hysterectomy and pelvic lymphadenectomy, adjuvant chemoradiotherapy resulted in better survival than radiotherapy alone. The addition of weekly cisplatin to radiotherapy is recommended. The treatment-related morbidity is tolerable.

Prediction of outcome of patients with metastatic breast cancer: evaluation with prognostic factors and Nottingham prognostic index.

Goals of workThe purpose of this study is to analyze the survival rate of patients with metastatic breast cancer and to evaluate the outcome of these patients using prognostic factors and Nottingham prognostic index.Materials and methodsFrom February 1992 to August 2008, 135 patients with metastatic breast cancer were treated at the Changhua Christian Hospital. In these patients, we evaluated the significance of the following factors in predicting the survival rate after the occurrence of metastasis: age, initial stage at primary diagnosis, histological grade, Karnofsky performance status (KPS), estrogen receptor (ER), progesterone receptor status, human epidermoid growth factor receptor 2 overexpression status, number of axillary lymph node metastasis, history of adjuvant radiotherapy and/or chemotherapy, disease-free interval, status of local recurrence, status of various sites of distant metastases, number of distant metastases, and Nottingham prognostic index.Main resultsThe 1-, 2-, and 5-year survival rates were 53.3%, 25.2%, and 1.5%, respectively. In the univariate analysis, KPS, histological grade, ER status, initial stage at primary diagnosis, number of axillary lymph node metastasis, liver metastasis, disease-free interval, first-/second-/third-line chemotherapy for recurrence or metastasis, number of metastases, and Nottingham prognostic index had significant impact on survival. The median survival of patients determined as corresponding to Nottingham low-risk group, intermediate-risk group, and high-risk group was 29.3, 17.9, and 4.6 months, respectively. In our multivariate analysis, Karnofsky performance status (p = 0.030) and Nottingham prognostic index (p ≤ 0.0001) were significant prognostic factors for survival, while first-/second-/third-line chemotherapy for recurrence or metastasis (p = 0.002) was a significant predictor for the outcome of the treatment.ConclusionsThe prognosis of patients with metastatic breast cancer is poor. In spite of the fact that many advances in treatment have been made, numerous additional questions have arisen; new drugs and therapeutic regimens are needed to improve the outcomes of patients, and further well-designed randomized trials are warranted.

Prognostic Factor Affecting the Outcome of Bone Metastasis from Hepatocellular Carcinoma

Purpose: The purpose of this study is to analyze the overall survival rate of patients with bone metastasis from hepatocellular carcinoma (HCC) and prognostic factors affecting their outcomes.Materials and Methods: From June 1999 to January 2005, there were 69 patients with bone metastasis from HCC who were treated at our hospital. The variables, such as gender, age of diagnosis of bone metastasis, Pughs modification of Childs grading of cirrhosis Okuda staging system, performance status, serum level of α-fetoprotein at diagnosis of bone metastasis from HCC, methods of treatment for bone metastasis, site of bone metastasis and metastasis to organ other than bones were analyzed about their influence upon prognosis.Results: Fifty-two patients (75.4%) are male and 17 patients (24.6%) are female. The medium age of diagnosis of bone metastasis was 66 years old (range from 31 to 78 years old). The medium survival from diagnosis of bone metastasis was 3.06 months. The 6-month, 1-year and 2-year overall survival rates were 30.43%, 11.59% and 5.80%, respectively. In univariate analysis, Childs grading of cirrhosis (p=0.0022), Okuda staging system (p=0.0002), and performance status (p=0.0277) were statistically significant factors for survival. In multivariate analysis, performance status (p=0.003) was the only significant prognostic factor.Conclusion: The survival of patients with bone metastasis from HCC was poor. To improve the outcome, we should enroll more patients and arrange prospective trial by combination of locoregional and systemic therapy.

Occult Breast Cancer Presenting as Axillary Nodal Metastases-A Case Report and Review of the Literature

We report a case of a 53-year-old female with occult breast cancer presenting with right axillary lymph nodes metastases. The initial presentation was swelling and pain of right axilla without palpable breast mass. Mammography revealed no mass or microcalcification in breast tissue except multiple hyperdense right axillary lymphadenopathy. Positron-emission tomography scan showed increasing FDG uptake of right axillary and right supuraclavicular lymph nodes. Biopsy of lymph node revealed metastatic carcinoma with positive estrogen receptor and progesterone receptor. These data suggested an occult cancer of the breast with right axillary lymph nodes metastases. The patient received right axillary lymph nodes dissection followed by chemotherapy with lipodox and taxotere. Adjuvant radiotherapy to the right breast and right supraclavicular area was given. The patient is well without evidence of disease after the treatment.

Radiation therapy with or without hormonal therapy for prostate carcinomafor prostate carcinoma

Purpose : Radical prostatectomy and radiation therapy are the main methods of treat-ment for prostate cancer. The goal of this study is to evaluate the outcomes and prog-nostic factors for patients with prostate cancer treated with radiation therapy alone or combined radiation and hormonal therapy. Materials and Methods : From January 2000 through July 2004, there were 67 men diagnosed with prostate cancer and referred to radiation oncology for radiotherapy in our hospital. The median age of patients at the time of diagnosis was 75 years. The patho-logic types were all adenocarcinoma. The median of Gleason score was 6. According to staging system of AJCC 1997, forty patients (59.7%) were stage II (T1N0M0 AnyG, T2N0M0 AnyG), eighteen patients (26.9%) were stage III (T3N0M0 AnyG), and 9 patients (13.4%) were stage IV (T4N0M0 AnyG, AnyTN1M0 AnyG). Four patients (6.0%) did not finish the radiation therapy course and were lost to follow up. Among the 63 patients who finished the therapy course, thirty-seven patients (58.7%) received radio-therapy alone, and 26 patients (41.3%) received combinations of radiation and hormonal therapy. The method of radiotherapy was 3-D conformal radiation therapy (3DCRT), and the median dose of radiation therapy was 7200 cGy. The variables, such as age, PSA level before treatment, Gleason score, maximum of Gleason grade, stage, methods of treatment and dose of radiotherapy were analyzed with respect to their influence upon prognosis. Univariate and multivariate analyses were used. Univariate analysis using the log rank test and multivariate analysis using the Cox proportional hazards model were performed. Overall survival rate, disease-specific survival rate, survival rate without clini-cal failure and survival rate without biochemical failure were calculated with the method of Kaplan and Meier. Results : Two patients were lost to follow up after completion of radiotherapy. The medi-an of follow-up duration was 27.8 months (range from 4.3 to 65.0 months). Therefore, sixty-one patients entered the analysis of results. Five-year overall survival rate was 91.11%. Five-year survival rate without clinical failure was 70.15%. Five-year survival rate without biochemical failure was 56.50%. Five-year disease-specific survival rate was Purpose : Radical prostatectomy and radiation therapy are the main methods of treat-ment for prostate cancer. The goal of this study is to evaluate the outcomes and prog-nostic factors for patients with prostate cancer treated with radiation therapy alone or combined radiation and hormonal therapy. Materials and Methods : From January 2000 through July 2004, there were 67 men diagnosed with prostate cancer and referred to radiation oncology for radiotherapy in our hospital. The median age of patients at the time of diagnosis was 75 years. The patho-logic types were all adenocarcinoma. The median of Gleason score was 6. According to staging system of AJCC 1997, forty patients (59.7%) were stage II (T1N0M0 AnyG, T2N0M0 AnyG), eighteen patients (26.9%) were stage III (T3N0M0 AnyG), and 9 patients (13.4%) were stage IV (T4N0M0 AnyG, AnyTN1M0 AnyG). Four patients (6.0%) did not finish the radiation therapy course and were lost to follow up. Among the 63 patients who finished the therapy course, thirty-seven patients (58.7%) received radio-therapy alone, and 26 patients (41.3%) received combinations of radiation and hormonal therapy. The method of radiotherapy was 3-D conformal radiation therapy (3DCRT), and the median dose of radiation therapy was 7200 cGy. The variables, such as age, PSA level before treatment, Gleason score, maximum of Gleason grade, stage, methods of treatment and dose of radiotherapy were analyzed with respect to their influence upon prognosis. Univariate and multivariate analyses were used. Univariate analysis using the log rank test and multivariate analysis using the Cox proportional hazards model were performed. Overall survival rate, disease-specific survival rate, survival rate without clini-cal failure and survival rate without biochemical failure were calculated with the method of Kaplan and Meier. Results : Two patients were lost to follow up after completion of radiotherapy. The medi-an of follow-up duration was 27.8 months (range from 4.3 to 65.0 months). Therefore, sixty-one patients entered the analysis of results. Five-year overall survival rate was 91.11%. Five-year survival rate without clinical failure was 70.15%. Five-year survival rate without biochemical failure was 56.50%. Five-year disease-specific survival rate was 93.57%. In univariate analysis of 3-year survival , PSA level before treatment and maxi- mum of Gleason grade were significant predictors for survival rate without biochemical failure (p= 0.0046, 0.0481, respectively). Hormonal therapy was not a significant predic- tor for survival. Conclusion : In this study, patients who had higher initial PSA level or maximum of Gleason grade had worse outcome. More aggressive treatment may be considered for these patients.

The Role of Radiotherapy in the Treatment of Non-Melanomatous Cancers of the Skin

Purpose: To evaluate the treatment results and analyze the prognostic factors of radiotherapy for skin malignancies. Materials and Methods: From January 1994 to April 2004, 48 patients with malignant skin cancer received a complete course of radiotherapy at Changhua Christian Hospital. There were 22 males and 26 females, between 38 and 94 years old (median: 78 years). The numbers of patients in stage I to IV were 16, 21, 11, and 0, respectively. The subtypes of histology were Squamous cell carcinoma (SCC) in 27 patients (56.3%), and Basal cell carcinoma (BCC) in 21 patients (43.8%). The median tumor size was 3 cm. Tumors location was predominantly at nose (29.2%), scalp (25%), facial (18.8%), extremities (8.3%), ear (6.3%), eyelids (4.2%) and others (8.3%). The median radiation dose and total treatment days were 60 Gy and 48 days. Results: The patients were followed up until October 2004. The median duration of follow-up was 26 months (range: 5.8 to 118.8 months). The 5-year overall survival and disease-free survival rate were 56.2% and 37.8%, respectively. Treatment failure included loco-regional relapse (8 patients), and distant metastasis (3 patients). In univariate analysis of variables with log rank test, AJCC stage, histology type and nodal metastasis were the significant prognostic factors (P＜0.05) for overall survival. Conclusion: Radiotherapy is effective in treatment of skin cancers. Our data indicated that the overall survival, disease-free survival, cosmetic appearance and patient tolerance were good and feasible.

Prognostic Factors Affecting the Outcome of Endometrial Cancer

Purpose: To evaluate the prognostic factors and treatment outcomes in patients of endometrial cancer with treatments of surgery followed by radiotherapy. Materials and Methods: From August 1993 to April 2004, there were 69 patients diagnosed as endometrial cancer at our hospital. The median age at diagnosis was 55 years (ranged from 34 to 80 years). According to the FIGO staging system for cancer of the uterine body, 46 patients (67%) were stage Ⅰ, 8 (12%) were stage Ⅱ, 12 (17%) were stage Ⅲ, and 3 (4%) were stage Ⅳ. Fifty-eight patients (84%) had endometrioid carcinomas and 11 patients (16%) had non-endometrioid carcinomas: 4 were leiomyoscarcomas, 3 were MMMTs (malignant mixed mullerian tumor), 2 were papillary serous carcinomas, 1 was clear cell carcinoma, and 1 was mixed mucinous and small cell carcinoma. All 69 patients underwent surgery. Sixty-three (91%) of these 69 patients received postoperative adjuvant radiotherapy. Results: The median follow-up duration was 38 months (ranged from 8 to 129 months). During the follow-up period, 60 patients (87%) were alive, and 9 patients (13%) died. Three patients (4%) had local recurrence. Nine patients (13%) had distant metastases. The actuarial 5-year overall survival rate was 85%. In univariate analysis, stage was a significant prognostic factor for overall survival, favoring early stages (p=0.0298). Pathological cell type was also a prognostic factor for overall survival, favoring cell type of endometrioid carcinoma (p=0.0063). Lymph node metastasis was another significant prognostic factor affecting overall survival, favoring status without lymph node metastasis (p=0.0469). In multivariate analysis, pathological cell type continued to be a significant prognostic factor for overall survival, favoring cell type of endometrioid carcinoma (p=0.045). Conclusions: The 5-year overall survival rate of 85% was achieved in our report of patients of endometrial cancer treated with surgery followed by radiotherapy. Stage, pathological cell type and lymph node metastasis were significant prognostic factors affecting overall survival based on our study. Longer follow-up of these patients and accrual of more patients are needed to evaluate long-term survival and treatment outcomes.

Treatment Results of Chemotherapy and Radiotherapy in Limited-Stage Small Cell Lung Cancer

Purpose: The purpose of our study was to evaluate the treatment results and to analyze the prognostic factors affecting the outcome of limited-stage small cell lung cancer patients treated with combined chemotherapy and radiotherapy. Materials and Methods: From January 1997 through September 2003, there were 27 patients diagnosed as limited-stage small cell lung cancer in Changhua Christian Hospital, Taiwan. Among the 27 patients treated with chemotherapy and radiotherapy, 22 (82%) were male and 5 (18%) were female. The median age of diagnosis was 61 years. According to the ECOG (Eastern Cooperative Oncology Group) performance status scaling system, 3 patients (11%) were ECOG 0, 20 patients (74%) were ECOG 1, and 4 patients (15%) were ECOG 2. The treatments consisted of either concurrent chemoradiotherapy (CCRT) or chemotherapy followed by radiotherapy. Chemotherapy regimens were cisplatin and etoposide. The median thoracic irradiation dose was 55.8 Gy (range: 45-64.8 Gy). Results: There were 15 patients (55%) achieving complete response, and 4 patients (15%) having partial response, with a total local response rate of 70%. Only one patient (7%) had local relapse out of 15 patients with complete tumor response. A total of 14 patients achieved local regional control (52%, 14 out of total 27 patients). Thirteen patients (48%) had distant metastasis, and 9 patients (69%) died of their diseases during the follow-up periods. The mean survival time was 28 months. In survival analysis, the 1- year, 2-year and 5-year overall survival rates were 67%, 54% and 43%, respectively. The 1-year, 2-year and 5-year disease-free survival rates were 68%, 36% and 22%, respectively. The 1-year, 2-year and 5-year disease-specific survival rates were 67%, 58% and 46%, respectively. In prognostic factors analysis, cumulative irradiation dose (p=0.018) was a predictor for local response. Body weight loss (p=0.010), cycles of chemotherapy (p=0.007) and local response (p=0.032) were prognostic factors for overall survival. Body weight loss (p=0.037), cycles of chemotherapy (p=0.001) and distant metastasis (p=0.001) were prognostic factors for disease-free survival. Body weight loss (p=0.004), cycles of chemotherapy (p=0.030) and local response (p=0.050) were prognostic factors for disease-specific survival. Conclusion: Chemotherapy of cisplatin and etoposide combined with radiotherapy is a feasible treatment modality for patients of limited-stage small cell lung cancer. A local response rate of 70%, and a 2-year overall survival of 54% were achieved. However, distant failure is still the major concern affecting survival in our present study. Among the 15 patients died of their diseases, 9 patients (60%) were dead due to distant metastasis. The modifications of chemotherapy regimens and radiotherapy techniques in further clinical trials are warranted to explore an optimal treatment and to achieve a satisfactory out- come for limited-stage small cell lung cancer.

Craniopharyngioma in a 70-Year-Old Male: Case Report and Review of Literature

Craniopharyngiomas are rare brain tumors in the hypothalamo-pituitary region. They are most commonly diagnosed in the young age. We report a 70-year-old man with craniopharyngioma treated with surgery and radiotherapy, and also reviewed the literatures of craniopharyngiomas.