Mitsuhiro Takahashi

Analysis of recurrence of squamous cell carcinoma of the uterine cervix after definitive radiation therapy alone: patterns of recurrence, latent periods, and prognosis

PURPOSE A retrospective analysis was performed with emphasis on the patterns of recurrence, latent period, and prognosis in patients with cervical squamous cell carcinoma of the uterus treated with definitive radiation therapy alone. Late recurrence, which was observed more than 5 years after the initial radiation therapy, was finally focused on and discussed. MATERIALS AND METHODS Between 1976 and 1994, 256 patients with squamous cell carcinoma of the uterine cervix without hematogenous metastasis were treated with definitive radiation therapy alone. The patients were staged as follows according to the FIGO classification: 26 in Stage I, 56 in Stage II, 124 in Stage III, 28 in Stage IVa, and 22 in Stage IVb. All the patients were treated with external beam irradiation and low-dose-rate intracavitary brachytherapy. RESULTS A total of 74 patients had recurrence. The recurrence appeared in 67 cases (90.5%) within 5 years. Metastasis to para-aortic and/or supraclavicular nodes developed later than other types of recurrence. Among patients with lymphogenous metastasis, there were more 5-year survivors after recurrence than with other types of recurrence. Patients with early recurrence, within 2 years of the initial therapy, had a worse prognosis than those with recurrence more than 2 years after treatment. Seven patients (2.7%) in all developed late recurrence more than 5 years after the treatment. The first site of recurrence was an abdominal para-aortic or supraclavicular node in all patients, excluding one patient who developed intrapelvic lymph node metastasis. Six patients had pelvic node metastasis detected with lymphangiography at the initial treatment. Median survival after late recurrence was 16.0 months. Two of 7 patients survived more than 3 years after secondary radiation therapy, and the remainder died of recurrent disease. CONCLUSION Patients with para-aortic and/or supraclavicular node metastasis that developed late after the initial treatment are more likely to survive due to secondary radiation therapy. Careful follow-up is emphasized for long-term survivors.

Radiation therapy for esophageal cancer in patients over 80 years old

PURPOSE A retrospective analysis was performed to investigate the treatment outcome and the significance of radiation therapy for esophageal cancer in patients over 80 years old. METHODS AND MATERIALS Between 1971 and 1990, 257 patients with squamous cell carcinoma of the esophagus were treated by radiation therapy. Of these, 40 patients over eighty years old were investigated. The reasons for radiation therapy were advanced age alone in 22 patients, Stage IV disease in 13, and medical problems in 5. Of these, 33 patients (83%) could be irradiated over 60 Gy. The cases with Stage I to III disease who received 60 Gy or more were defined as the curative radiation therapy group, and the others were defined as the palliative radiation therapy group. Actuarial survival rates were determined by the Kaplan-Meier method. RESULTS The 5-year disease-specific survival rate for the curative radiation therapy group (n = 25) was 34% with three intercurrent deaths. None of the patients in the palliative radiation therapy group (n = 15), including 13 cases with Stage IV and two given-up cases, survived over 2 years. No severe radiation damage was observed in either group. The 5-year disease-specific survival rate was 64% for complete response cases of local response, and 8% for partial response and no change cases (p < 0.01). The 5-year disease-specific survival rate was 64% for the patients with tumors less than 5 cm in length, and 8% for the patients with tumors over 5 cm in length (p < 0.001). No significant survival differences were found in regard to sex and tumor location. The patients with superficial spreading type and polypoid type tumors according to the radiologic findings had better prognoses than the patients with ulcerative type and circumferential type tumors. CONCLUSIONS Radiation therapy is a safe and effective treatment for esophageal cancer in patients over 80 years old.

Brachytherapy for penile cancer using silicon mold

We analyzed the treatment results of 15 patients with penile cancer treated by afterloading brachytherapy with a silicon-made mold we devised. The group included 8 patients with T1, 5 with T2 and 2 with T3 tumors, and inguinal lymph node metastases were noted in 4 patients. The total dose of brachytherapy ranged from 32 to 74 Gy with or without an electron beam boost. The median dose rate was 200 cGy/h ranging from 100 to 350 cGy/h. Local control was achieved in 12 of the 15 patients (80%), and was related to the T category, with 100% of T1 and 80% of T2, in contrast to 0% of T3 tumor. Three patients with partial response or residual tumor underwent amputation. Local recurrence was recognized in 1 patient with a T2 tumor, but salvaged by surgery. Penis conservation was achieved in 11 of 15 patients (73%). Of the 4 patients with inguinal lymph node metastases, 3 were controlled by surgery and radiation therapy. The other with a T3 tumor died from the disease. Brachytherapy with a mold for penile cancer was considered to be the first choice for penis-conserving therapy, and the patients with T1 and T2 tumors have good indications for this method of treatment.

EVALUATION OF EXTERNAL BEAM THERAPY AND THREE BRACHYTHERAPY FRACTIONS FOR CARCINOMA OF THE UTERINE CERVIX

PURPOSE A retrospective analysis was performed to evaluate external beam therapy and three brachytherapy fractions for patients with squamous cell carcinoma of the uterine cervix, compared with those with other histological types. METHODS AND MATERIALS Three hundred and twenty-two patients with carcinoma of the uterine cervix received external pelvic irradiation combined with three sessions of low dose rate intracavitary irradiation within 6 weeks. Two hundred and ninety-three patients had squamous cell carcinoma (SCC), whereas 29 patients had nonsquamous cell histology (N-SCC): 18 had adenocarcinoma, 5 had undifferentiated carcinoma, 4 had adenosquamous carcinoma, and 2 had adenoacanthoma. Survival rates, patterns of failure, local control rates, and complications in the patients with SCC were compared with those in the patients with N-SCC. RESULTS The 5-year overall actuarial survival rates for the patients with SCC and for those with N-SCC were: 84% and 100% in Stage I disease, 72% and 38% in Stage II disease, 52% and 17% in Stage III disease, and 29% and 0% in Stage IV disease, respectively. The 5-year cause specific survival rates for the patients with SCC in Stages I to IV disease were 100%, 87%, 72%, and 39%. Corresponding rates for the patients with N-SCC were 100%, 43%, 25%, and 0%. There was a statistically significant difference between the survival curves for two histological types in Stage II B, III B, and IV A diseases. The local control for the patients with N-SCC was worse than in the patients with SCC. The crude moderate and severe rectal complication rates (Grades 3 and 4) for the patients with SCC and for the patients with N-SCC were 7.5% and 3.4%, respectively. Only one patient with SCC developed chronic small intestinal injury in this series. We observed four patients with SCC who developed Grade 2 and four with Grade 4 urinary bladder complications. CONCLUSIONS Three sessions of intracavitary brachytherapy were a safe and effective procedure for the patients with SCC and the outcome of radiation therapy in the patients with SCC was satisfactory even in advanced cases. However, local control of N-SCC is difficult to achieve by this method and the prognosis for patients with N-SCC was significantly worse than that for patients with SCC.

Clinical study of radioprotective effects of amifostine (YM-08310, WR-2721) on long-term outcome for patients with cervical cancer

PURPOSE A retrospective analysis was performed to investigate the radioprotective effects of amifostine on the long-term outcome of radiation therapy for the patients with carcinoma of the uterine cervix. METHODS AND MATERIALS Eighty-three patients with histologically proven epidermoid carcinoma (Stage II-IVA disease) of the uterine cervix were treated with definitive radiation therapy between January 1978 and December 1984. Forty-six patients treated with radiation alone, whereas 37 patients treated with radiation plus amifostine. Amifostine was given intravenously 30 min prior to every radiation. Most patients received 75 mg/m2 of amifostine daily from the initiation of the course of radiation therapy. The median total dose of amifostine given was 1300 mg/m2, with a range of 280 mg/m2 to 3700 mg/m2. RESULTS The 5-year overall actuarial survival for the patients treated with radiation alone and with radiation plus amifostine were: 72% and 88% in Stage II disease (p = 0.45); 52% and 50% in Stage III disease (p = 0.68); and 40% and 43% in Stage IVA disease (p = 0.51), respectively. The 5-year intra-pelvic recurrence rates in the patients treated with amifostine were almost the same as those observed in the patients treated without amifostine (0% vs. 6% in Stage II disease; 15% vs. 10% in Stage III disease; 25% vs. 40% in Stage IVA disease). There was also no statistically significant difference of the chronic rectal or bladder complication rate between the groups treated by each regimen. CONCLUSION We concluded that any radioprotective effects of amifostine on tumor tissue and any beneficial effects of amifostine against chronic radiation injury were not observed in the patients with cervical cancer followed up for more than 5 years after radiation therapy.