Simon G. Tang

Randomized Trial of Neoadjuvant Cisplatin, Vincristine, Bleomycin, and Radical Hysterectomy Versus Radiation Therapy for Bulky Stage IB and IIA Cervical Cancer

PURPOSE To compare the efficacy of neoadjuvant chemotherapy (NAC) followed by radical hysterectomy with that of radiotherapy (R/T) for bulky early-stage cervical cancer. PATIENTS AND METHODS Women with previously untreated bulky (primary tumor >/= 4 cm) stage IB or IIA non-small-cell carcinoma of the uterine cervix were randomly assigned to receive either cisplatin 50 mg/m(2) and vincristine 1 mg/m(2) for 1 day and bleomycin 25 mg/m(2) for 3 days for three cycles followed by radical hysterectomy (NAC arm) or receive primary pelvic radiotherapy only (R/T arm). The ratio of patient allocation was 6:4 for the NAC and R/T arms. Women with enlarged para-aortic lymph nodes on image study were ineligible unless results of cytologic or histologic studies were negative. RESULTS Of the 124 eligible patients, 68 in the NAC arm and 52 in the R/T arm could be evaluated. The median duration of follow-up was 39 months. Thirty-one percent of patients in the NAC arm and 27% in the R/T arm had relapse or persistent diseases after treatment, and 21% in each group died of disease. Estimated cumulative survival rates at 2 years were 81% for the NAC arm and 84% for the R/T arm; the 5-year rates were 70% and 61%, respectively. There were no significant differences in disease-free survival and overall survival. CONCLUSION NAC followed by radical hysterectomy and primary R/T showed similar efficacy for bulky stage IB or IIA cervical cancer. Further study to identify patient subgroups better suited for either treatment modality and to evaluate the concurrent use of cisplatin and radiation without routine hysterectomy is necessary.

A multivariate analysis of prognostic factors in management of pineal tumor

PURPOSE A multivariate analysis of prognostic factors of treatment outcome of pineal tumor. METHODS AND MATERIALS From February 1979 to June 1987, 25 patients with primary pineal tumors were treated in our department. Patients were treated with either AECL Co-60 unit or 10 MV linear accelerator to the primary tumor with an adequate margin or to the whole brain (median dose of 36 Gy) with or without a cone-down boost of 10 to 20 Gy. Craniospinal irradiation was performed in two patients with positive CSF cytology. Minimum follow-up was 40 months. Patients were further stratified according to tumor type. Group I consisted of seven patients with pineal germinoma. Group II included nine patients with nongerminoma, and Group III represented nine patients treated without a histological verification but clinical diagnosis. RESULTS The relapse-free survival (RFS) of Group I patients was 100% and 86% at 2 and 5 years, respectively. Relapse-free survival was 55% and 21% at 2 and 5 years, respectively, for Group II patients. Six of 9 patients in Group II died of disease due to either local recurrence or tumor seeding. Eight of 9 patients in Group III remain no evidence of disease, and RFS was 89% at 2 and 5 years. Multivariate analysis revealed that tumor histology is the only significant prognosticator. Age, gender, type of surgical procedure, RT field, and tumor dose were not. Coxs regression model also failed to demonstrate a significant correlation of tumor seeding with the type of surgery. CONCLUSION The type of tumors in the pineal region dictates the treatment outcome. Definitive radiation therapy is effective in controlling germinoma, whereas a more aggressive approach is needed to improve local control for nongerminoma. For a localized pineal lesion, we advocate that treatment can be tailored to the primary tumor with adequate margins. However, for locally advanced tumors whole brain or craniospinal irradiation should be considered. No definitive correlation between type of surgery and the probability of tumor seeding was identified.

Treatment OF Nasopharyngeal Carcinoma With Unusual Histological Features

Purpose: To evaluate the treatment results and relapse patterns for nasopharyngeal carcinomas (NPCs) with unusual histological features. Materials and Methods: From Dec 1983 to April 1997, nine cases of carcinoma occur-ring in the nasopharynx, which were characterized by unusual histological presentations, underwent radiotherapy at the Department of Radiation Oncology, Chang Gung Memorial Hospital-Linkou. The histological diagnoses for these patients were adenoid cystic carcinoma (n= 4), poorly differentiated adenocarcinoma (n= 3), and mucoepider-moid carcinoma (n= 2). This group consisted of two females and seven males, with a median age of 41 years (range, 15 to 72). Two patients with mucoepidermoid carcinoma and one with the adenoid cystic variant underwent transpalate excision of the tumor before irradiation. All patients were treated with definite irradiation, with total dose to the nasopharynx ranging from 6480 to 7280 cGy (median, 7080). Results: The five and ten-year overall survival rates, derived using the Kaplan-Meier method, were 44.4% and 29.6%, respectively. Median survival was 2.73 years. Local recurrence occurred for six of the patients (66%). The duration to local recurrence varied from 12 to 113 months, with a median of 33 months. Two patients developed distant metastasis to lung or liver. Conclusion: Nasopharyngeal carcinomas with unusual histological features are rare. As a result, the small number of such cases diagnosed during the study period limited the statistical power of this study. Relatively advanced stage distribution and a greater proportion of local relapse after definite radiotherapy were observed, with these features probably accounting for the poor survival rate for NPC cases which are characterized by unusual histological features.

Endocrine Dysfunction in Patients with Nasopharyngeal Carcinoma after Radiotherapy -A Prospective Study with 10 Years Follow-Up

Purpose: To investigate the late endocrine dysfunction in patients with nasopharyngeal carcinoma (NPC) following radiotherapy (RT). Materials & Methods: The endocrine function in 5 NPC patients (3 male and 2 female) treated with RT alone was analyzed in this study. Estimated doses to the hypothalamus, pituitary, and thyroid were 49.4-66.6 Gy, 50.9-70.2 Gy and 46.8 Gy, respectively. Growth hormone (GH), cortisol response to insulin tolerance test (In), thyroid-stimulating hormone (TSH) response to TRH and gonadotropin response to LHRH were measured before, at 1.5 years and at 10 years after RT. The basal levels of prolactin, estradiol or testosterone, total triiodothyronine, and thyroxine were also measured at these time points. Results: The pre-treatment endocrine function was normal in all patients. All of them developed GH deficiency and 2 patients with clinical symptoms of hypothyroidism had increased basal level of TSH at 10 years after RT. TSH responses to TRH were increased in 3 patients and delayed in 1 patient. One female patient developed amenorrhea and had decreased cortisol response to ITT. No hyperprolactinemia was observed in these patients. Conclusion: Endocrine dysfunction is a common complication in NPC patients following RT. The hypothalamic-pituitary region and thyroid gland should be shielded as much as possible if the possibility of cure is not compromised. Regular endocrine assessment and replacement of deficient hormone might be indicated in NPC patients following RT.