M.E. Shukla

Impact of postmastectomy radiation on locoregional recurrence in breast cancer patients with 1-3 positive lymph nodes treated with modern systemic therapy.

PURPOSE Postmastectomy radiation therapy (PMRT) remains controversial for patients with 1-3 positive lymph nodes (LN+). METHODS AND MATERIALS We conducted a retrospective review of all 369 breast cancer patients with 1-3 LN+ who underwent mastectomy without neoadjuvant systemic therapy between 2000 and 2007 at Cleveland Clinic. RESULTS We identified 271 patients with 1-3 LN+ who did not receive PMRT and 98 who did receive PMRT. The median follow-up time was 5.2 years, and the median number of LN dissected was 11. Of those not treated with PMRT, 79% received adjuvant chemotherapy (of whom 70% received a taxane), 79% received hormonal therapy, and 5% had no systemic therapy. Of the Her2/neu amplified tumors, 42% received trastuzumab. The 5-year rate of locoregional recurrence (LRR) was 8.9% without PMRT vs 0% with PMRT (P=.004). For patients who did not receive PMRT, univariate analysis showed 6 risk factors significantly (P<.05) correlated with LRR: estrogen receptor/progesterone receptor negative (hazard ratio [HR] 2.6), lymphovascular invasion (HR 2.4), 2-3 LN+ (HR 2.6), nodal ratio >25% (HR 2.7), extracapsular extension (ECE) (HR 3.7), and Bloom-Richardson grade III (HR 3.1). The 5-year LRR rate was 3.4% (95% confidence interval [CI], 0.1%-6.8%] for patients with 0-1 risk factor vs 14.6% [95% CI, 8.4%-20.9%] for patients with ≥2 risk factors (P=.0006), respectively. On multivariate analysis, ECE (HR 4.3, P=.0006) and grade III (HR 3.6, P=.004) remained significant risk factors for LRR. The 5-year LRR was 4.1% in patients with neither grade III nor ECE, 8.1% with either grade III or ECE, and 50.4% in patients with both grade III and ECE (P<.0001); the corresponding 5-year distant metastasis-free survival rates were 91.8%, 85.4%, and 59.1% (P=.0004), respectively. CONCLUSIONS PMRT offers excellent control for patients with 1-3 LN+, with no locoregional failures to date. Patients with 1-3 LN+ who have grade III disease and/or ECE should be strongly considered for PMRT.

Evaluation of the Current Prostate Cancer Staging System Based on Cancer-Specific Mortality in the Surveillance, Epidemiology, and End Results Database

BACKGROUND Prostate cancer is the most common noncutaneous malignancy diagnosed in men. From a large population-based database, this study aimed to report prostate cancer-specific mortality (PCSM) rates of men diagnosed with various presentations of prostate cancer and to examine the adequacy of the current American Joint Committee on Cancer (AJCC) staging system. PATIENTS AND METHODS The Surveillance, Epidemiology, and End Results (SEER) database was queried for all patients diagnosed with prostate cancer from 1997 to 2005. PCSM was reported by the classification of extent of disease provided by the SEER database, for clinically staged and pathologically staged cohorts. RESULTS Using the cumulative incidence method, PCSM at 10 years for all patients (n = 354,326) was 5% for clinically localized (CL) lesions, 7% for T3aN0M0, 14% for T3bN0M0, 26% for T4N0M0, 27% for TanyN1M0, and 66% for TanyNanyM1. Within the pathologically staged subgroup (n = 108,135), PCSM at 10 years was 1% for CL lesions, 4% for T3aN0M0, 9% for T3bN0M0, 9% for T4N0M0, and 19% for TanyN1M0. CONCLUSION Staging of any disease site aims to accurately communicate, prognosticate, and guide management for that particular level of disease. Stage IV prostate cancer is a diverse group, with PCSM in the subgroups ranging from 9% to 68% in this study. Considering the favorable outcomes of those with T4 or N1 nonmetastatic prostate cancer relative to those with M1 disease, the authors propose that T4 or N1 M0 prostate cancer should be reclassified into a new stage IIIB and that patients with such disease should be offered curative-intent therapy whenever possible.

Stereotactic body radiotherapy for a large arteriovenous malformation of the head and neck

Large arteriovenous malformations (AVMs) of the head and neck present a treatment challenge. A 38‐year‐old woman presented with a large intraoral bleed from longstanding AVMs of the left infratemporal fossa and the right tongue, despite 10 prior surgeries and embolizations. She was treated with stereotactic body radiotherapy with a dose of 24 Gy in three weekly fractions. Four years later, she has had dramatic shrinkage of her AVM, no recurrent bleeding episodes, no further treatment required, and no significant late effects.

Identifying patients with node-positive prostate cancer who may benefit from adjuvant pelvic radiation following prostatectomy.

195 Background: Three PRTs address the role adjuvant radiotherapy (RT) following radical prostatectomy (RP) in men with locally advanced and/or margin positive prostate cancer (PCa), one of which demonstrated an improvement in overall survival by the addition of early RT. Not addressed in these studies is the role of adjuvant RT in lymph node positive (LN+) PCa. METHODS We reviewed an IRB-approved prospective database at the Cleveland Clinic and identified 84 men with non-metastatic, LN+ PCa treated with RP from 1987-2010. Men receiving neoadjuvant therapy or adjuvant RT were excluded from this analysis. Pelvic failure (PF) was defined as recurrence in the prostate bed or pelvic LN up to the common iliacs. Distant failures (DF) were defined as any LN recurrence beyond the common iliacs, bone, or other solid organ metastases. Kaplan-Meier estimates of pelvic failure (PF), distant failure (DF) and overall survival (OS) were conducted. RESULTS Median follow-up was 6 years. The median initial PSA was 10.1 ng/mL, 50% had Gleason 7, 12% had Gleason 8, 31% had Gleason 9 disease. The median number of LNs dissected was 11 (range 1-49) and 36% had >1 LN+. Extracapsular extension was present in 90%, seminal vesicle invasion in 66%, and surgical margins positive in 55%. The 6 week post-operative PSA was undetectable (<0.2 ng/ml) in 58%. Overall, 41% received immediate androgen deprivation therapy (ADT), and 45% received delayed ADT after biochemical or clinical failure, while 23% received salvage RT and 22% received chemotherapy. The 10-year OS was 61%. Clinically documented PF and DF occurred in 14% and 24%, respectively. Gleason score was the factor most predictive of PF, DF, and OS. Comparing Gleason score of ≤7 vs. ≥8, the 5-year PF rate was 3% vs. 24% (p=0.006), the 5-year DF rate was 2% vs. 37% (p<0.0001), and 5-year OS was 97% vs. 74% (p<0.0001), respectively. The number of LN+ was not prognostic. CONCLUSIONS Men with Gleason score ≥8 LN+ PCa have a high rate of pelvic recurrence, and pelvic radiation may be worthy of prospective investigation.