John T. Chaffey

Patterns of recurrence following curative resection of adenocarcinoma of the colon and rectum

This study explores the patterns of recurrence after “curative” operation for colorectal cancer. For an 11‐year period, 1960–1971, 281 evaiuable patients were resected at the Peter Bent Brigham Hospital. Crude five‐year survival in these patients was 49%, but only 10% of those with recurrence lived five years. A total of 69 patients relapsed during their lifetime and 34 additional patients were found to have metastases at death. The initial site of metastases was regional in 23 patients (33%) and distant in 32 (46%). Simultaneous regional and distant metastases were found in 13 (19%) for a total of 65% of patients having initial distant metastases. Approximate recurrence rates by site were: 30% for sigmoid and rectum, 20% for right colon, and 10% for transverse and left colon. Tumor size was a significant determinant of recurrence but did not select for regional or distant sites. Recurrence by Astler‐Coller modification of the Dukes‐Kirklin classification revealed 10% for A + B1, 33% for B2, 35% for C1, and 50% for C2. More than half of the patients with distant metastases (18/32) had solely hepatic metastases yet the total incidence of liver metastases as the initial site was only 8% of the total. In general, the site of the primary cancer was the most important determinant of the type of recurrence; the stage and site of the primary tumor were most predictive for eventual relapse.

Resectable adenocarcinoma of the rectosigmoid and rectum. I. Patterns of failure and survival.

In an effort to determine the patterns of failure and survival of rectosigmoid and rectal cancer, a retrospective review of 168 patients who underwent potentially curative surgery at the New England Deaconess Hospital was performed. The 5‐year actuarial survival for the entire group was 67%. Survival rates decreased with increasing penetration of the bowel wall by tumor and the presence of lymph node metastasis, but only the latter reached statistical significance. Those patients who underwent an abdominoperineal resection also experienced a significant decrease in survival compared to a low anterior resection. Patterns of failure, expressed as the actuarial incidence of first failure at 5 years, were examined by stage. With the exception of stages B3 and C3, there was a trend towards increased abdominal, distant, and total failure with increasing bowel wall penetration by tumor. A similar trend was seen in local failure in those patients with positive nodes. Knowledge of these data may help identify those patients who may benefit most from adjuvant therapy.

Potentially curative surgery of colon cancer: patterns of failure and survival.

In an effort to determine the patterns of failure and survival of colon cancer, a retrospective review of 294 patients who underwent potentially curative surgery at the New England Deaconess Hospital (NEDH) was performed. For the entire group, the 5-year crude survival rate was 68% and the actuarial rate was 80%. Survival decreased with increasing bowel wall penetration by tumor and the presence of lymph node metastasis. Although survival varied with the tumor site, none of the differences was statistically significant. Other variables, including the grade of adenocarcinoma, size, and the type of surgery had a significant impact on survival. Patterns of failure, expressed as the actuarial incidence of first diagnosed failure at 5 years, were examined by stage and site. There was a trend toward increased failure with increasing bowel wall penetration by tumor and the presence of lymph node metastasis. Abdominal failure, either as the only site or as a component of failure, was the most common type of failure. When compared by site, patients with cecal carcinoma had a significantly lower incidence of local and distant failure than patients with disease in other selected sites. No differences in patterns of failure were seen in patients with carcinomas in the mobile sections of the colon compared with those who had disease arising in the nonmobile sections of the colon. These data may be useful in identifying those patients who might benefit most from adjuvant therapy.

Results of treating stage III carcinoma of the breast by primary radiation therapy.

One hundred sixteen patients with stage III carcinoma of the breast were treated by primary radiation therapy. The 5‐year actuarial survival and relapsefree survival were 25% and 22%, respectively. The 5‐year actuarial probability of local tumor control for the entire group was 64%. In patients undergoing an excisional biopsy and an interstitial implant of the primary tumor area, local control was 100%. In patients who had either an excisional biopsy or an implant, the 5‐year actuarial probability of local control was 77% and 76%, respectively. In contrast, in patients having neither an excisional biopsy nor an implant, local control was only 41%. In patients receiving a total dose of greater than 6000 rad, from external beam treatment or from external beam plus an interstitial implant, the local control was 78% compared to 39% in patients receiving a total dose of less than 6000 rad. Forty‐one patients received some form of adjuvant therapy. Both local control and relapse‐free survival were improved in patients receiving chemotherapy as the sole adjuvant and in patients receiving chemotherapy combined with an endocrine ablative procedure. However, patients treated with only an endocrine ablative procedure had no improvement in survival nor in local control. These results indicate that primary radiation therapy can provide local control in a high proportion of patients with stage III carcinoma of the breast and suggest that chemotherapy is effective in improving both local control and survival in these patients. Cancer 43:985–993, 1979.

Resectable adenocarcinoma of the rectosigmoid and rectum. II. The influence of blood vessel invasion

Several series have examined the influence of blood vessel invasion (BVI) by tumor on survival of patients with colorectal cancer; however, little data are available regarding its influence on patterns of failure. In an effort to determine the influence of BVI on the patterns of failure and survival in rectosigmoid and rectal cancer, a retrospective review of 168 patients who underwent potentially curative surgery at the New England Deaconess Hospital was performed. In patients who had tumors with extramural BVI, there was a significant decrease in five‐year actuarial survival compared with patients who had tumors with intramural BVI or were BVI‐negative (BVI‐). When the intramural and extramural types of BVI were combined, no significant impact was noted on the patterns of failure or survival in patients with BVI+ versus those with BVI‐ tumors. In contrast, the presence of lymphatic vessel invasion was found to significantly decrease survival. By using a proportional hazards analysis, it was found that BVI was not an independent prognostic variable. Therefore, the use of BVI alone is not recommended for selecting patients with rectosigmoid and rectal cancer who may benefit from adjuvant therapy.

Primary radiation therapy for early breast cancer: The experience at the joint center for radiation therapy

Abstract The results of primary radiation therapy in 176 consecutive patients with clinical Stage I and II carcinoma of the breast were reviewed. Median follow-up time was 47 months. The overall breast relapse rate was 7%. Patients undergoing interstitial implantation had a significantly lower breast relapse rate (1%) than patients not undergoing implantation (11 %). Breast relapse was more common in patients undergoing incisional or needle biopsy (17 %), compared to patients treated after excisional biopsy (5 %). In patients undergoing excisional biopsy, but not interstitial implantation, breast relapse was related to external beam dose. Twelve percent of the patients who received less than 1600 ret dose relapsed in the breast, compared to none of the 19 patients who received more than 1700 ret dose. These results imply that supplemental irradiation to the primary tumor area is required following excisional biopsy of a primary breast cancer when 4500–5000 rad is delivered to the entire breast.

Radiation therapy in the management of patients with mesothelioma

The results of radiation therapy in the management of 27 patients with malignant mesothelioma were reviewed. Eight patients were treated with a curative intent combining attempted surgical excision of tumor (thoracic in 6 and peritoneal in 2), aggressive radiation therapy, and combination chemotherapy using an adriamycin-containing regimen. One patient achieved a 2-year disease-free interval followed by recurrence of tumor above the thoracic irradiation field. This patient was retreated with localized irradiation and is disease-free after 5 years of initial diagnosis. One patient has persistent abdominal disease at 18 months; the other 6 patients suffered local recurrence within 8-13 months of initiation of treatment. Radiation therapy was used in 19 other patients who received 29 courses for palliation of dyspnea, superior vena cava syndrome, dysphagia, or neurological symptoms of brain metastasis. A palliation index was used to determine the effectiveness of irradiation and revealed that relief of symptoms was complete or substantial in 5 treatment courses, moderately effective in 6 courses and inadequate in 18 treatment courses. Adequate palliation strongly correlated with a dose at or above 4,000 rad in 4 weeks. The management of patients with mesothelioma requires new and innovative approaches to increase the effectiveness of radiation therapy and minimize the significant potential combined toxicity of pulmonary irradiation and adriamycin.

Radiation therapy in the treatment of aggressive fibromatoses

Abstract Twelve patients with aggressive but histologically benign connective tissue tumors (nine desmoids and three neurofibromas) were treated with either radiation or radiation plus surgery. Long term local control was accomplished in eight of nine desmoid tumors and 2 of 3 neurofibromas. In the successfully treated patients, local control was obtained with minimal long term complications when compared with radical surgical procedures that would have been necessary for cure. Details of radiation treatment are discussed along with proposed indications for therapy.

Radiotherapy for prostate carcinoma: the JCRT experience (1968–1978). II. Factors related to tumor control and complications

We have analyzed treatment failure and complications as a function of radiotherapy technique and other factors in 229 patients irradiated for prostate carcinoma from 1968-1978. Thirty-four patients (15%) developed clinical evidence of local-regional recurrence. In about one-quarter of these recurrences, there was a component of ureteral obstruction, possibly due to marginal miss in the seminal vesicles. Although different parameters of treatment technique were not significantly correlated with local failure, there was a trend toward higher failure rates for Stage B and C patients when the length and/or width of the conedown field was less than 8 cm (p = 0.27 and 0.25, respectively). As in other recent studies, patients with Stage C disease who had undergone trans-urethral resection of the prostate had a lower disease-free survival rate than patients who had only needle biopsy (39 vs. 65% at 5 years, p = 0.055). The use of larger initial fields treating the pelvic lymph nodes did not result in better local tumor control or better overall control. However, the use of larger fields did result in a higher rate of significant complications (8.7 vs. 1.6% for fields greater than or equal to 150 cm2 or less than 150 cm2, respectively, p = 0.013). In view of the higher complication rate and the absence of convincing evidence of benefit for whole pelvic treatment, irradiation of all pelvic lymph nodes can be questioned.

Cardiac disease after mediastinal irradiation for seminoma.

One hundred twenty‐four patients with seminoma (119 primary testis, five primary extragonadal) were treated between 1968 and 1984 at the Joint Center for Radiation Therapy. Fifty‐seven of the 124 patients were treated with irradiation to the mediastinum as well as to an infradiaphragmatic field. One patient received supradiaphragmatic radiotherapy only. The remaining patients had radiation treatment limited to the infradiaphragmatic field only. Median dose to the mediastinum among the 58 patients was 2400 cGy. Four patients developed heart disease (one fatal myocardial infarction, one uncomplicated myocardial infarction, one constrictive pericarditis resulting in permanent total body anasarca, and one patient requiring aortic valve replacement and coronary artery bypass grafting for atherosclerotic disease) and two died suddenly. The two sudden deaths were thought to be cardiac in origin by the patients primary physicians. All six complications occurred in the group that received mediastinal irradiation. No cardiac disease was manifested in the group not treated with mediastinal irradiation. This difference in the incidence of cardiac disease between the two groups is statistically significant (two sided, P = 0.019). Neither group had a statistically significant difference in cardiac disease rate from a normal population (Framingham study), although the ratio of observed to expected cardiac disease was 1.97 in the group receiving mediastinal radiation. Further experience from this and other institutions is necessary to confirm this finding.