Thongbliew Prempree

The influence of patients' age and tumor grade on the prognosis of carcinoma of the cervix.

Many factors can influence the prognosis of cancer of the cervix. They range from clinical staging, various histologic cell types, to extensions into the endometrium. Very little is known about the influence of the patients‐ age and constitutional status of the host (patient) on the prognosis of cervical cancer. Over the past several years, we have been observing that when cancer of the cervix occurs in the relatively young patient, they tend to be more aggressive and inspite of the usual accepted treatment, the majority of them do not survive their disease. From 1969 to 1974, 561 patients with proven invasive squamous cell carcinoma of the cervix were treated by irradiation only in the Department of Radiation Therapy, University of Maryland Hospital. Of these, 94 patients were studied and their ages ranged from 23 to 39 years. They were staged following FIGO guidelines and subject to the usual irradiation treatment for cervical cancer. All patients are eligible for a minimum five‐year follow‐up and the absolute five‐year disease‐free survival is as follows: Stage I, 70.2%, (33/47); Stage II, 54%, (14/26); Stage III, 17%, (3/18) and Stage IV, 0%, (0/3). One of the most interesting features observed in Stage I and II disease is distant disease; 26% for Stage I and 42% for Stage II. Further analysis of our result for Stage I and II shows that tumor grading may be responsible for poor outcome. Three Grade systems were used for the study and the result clearly shows that Grade III or poorly differentiated squamous cell carcinoma had the poorest five‐year survival; for example, survival for Stage I disease is 43% and 44% for Stage II. Analysis of the failures following the treatment suggests that about 50% of patients with Grade III disease have already had distant disease by the time the diagnosis was made. Recommendations for futher appropriate treatment is suggested.

A THERAPEUTIC APPROACH TO EARLY VOCAL CORD CARCINOMA

One hundred and twenty patients with early glottic carcinoma received radiation therapy at the University of Maryland Hospital from 1959 to 1977. The radiation dose ranged from 55 Gy in 4 weeks for small T1a lesions to 65 Gy in 61/2 weeks for T2 lesions. The local control rates by irradiation alone for stages T1a, T1b, and T2 were 92, 91 and 88 per cent, respectively, while 5-year determinate disease-free survival rates were 96 per cent for stage I disease and 88 per cent for stage II disease. Most of the local failures were salvaged by surgery, with a low complication rate. Regional metastases were uncommon, and occurred in 7 per cent in stage I and in 6 per cent in stage II disease. Factors increasing the risk of failures appeared to be bulky tumor, anterior commissure involvement and subglottic extension.

Radiation treatment of recurrent carcinoma of the vulva

Recurrent vulvar cancer after surgical treatment carries a poor prognosis and poses a clinical therapeutic problem. Retrospective analysis of 21 recurrent vulvar cancer treated by radiation alone over 20 years (1958–1977) is presented. Highly individualized interstitial brachytherapy was used alone in some selected cases and combined with external beam therapy in most cases. The results showed that limited disease in the introitus and introitus involving the vagina have the best prognosis (6/6; 100%). Small groin node has a good chance for cure (2/4; 50%), while all extensive recurrences have the worse prognosis as expected. Factors responsible for the success of radiation treatment appear to include (1) size and depth of the recurrence (5 cm or less lesion has a high chance for cure); (2) groin node (≤2 cm has good prognosis); (3) perineal skin involvement (the lesser, the better); (4) degree of tumor tissue necrosis (the lesser, the better); and (5) radiation dose (5500–8500 rad). Integration of the external beam and brachytherapy and individualization with good planning are essential to achieve a better cure rate. Attempts were made to recommend a criteria for patient selection for cure and method of treatment as well as a technical aspect of the treatment.

Radiation management of primary carcinoma of the vagina

This 15‐year retrospective study includes 71 patients with diagnosis of primary carcinoma of the vagina treated at the University of Maryland Hospital, Radiation Therapy section from 1957 to 1970. The lesions were staged according to the system advocated by International Federation of Gynecology and Obstetrics (FIGO) with a minor modification (Perez et al.11). With the exception of Stage O, histologic diagnosis was 94% (60/64) invasive squamous cell carcinoma and 6.0% (4/64) adenocarcinoma. Of 71 cases who are eligible for a minimum five‐year follow‐up, the absolute five‐year cure rate for various clinical stages is as follows: Stage O 100% (7/7), Stage 1 83.2% (5/6), Stage 11A 65% (13/20), Stage 11B 63.5% (7/11), Stage 111 40% (8/20), Stage 1V 0% (0/7). The overall absolute five‐year cure‐rate for all stages combined was 56.3% (40/71). A comparable result and even better in some stages (II and III) as compared to several previous reports are thought to be due to the proper intergrated irradiation combining interstitial and intracavitary radium with external super‐voltage beam. Furthermore, an aggressive radium implant to the vagina, para‐colpium, and specifically to parametrium and pelvic wall in Stage II and III appears to be one of the keys to our good results. The technique of treatment, stage by stage, are being fully discussed along with a few complications and failures. Cancer 40:109–118, 1977.

Angiosarcomas of the uterus and ovary: Clinicopathologic report

The clinicopathologic features of Angiosarcomas of the uterus and ovary are described. Extensive review of world literature shows only eight reported cases of angiosarcoma arising in the uterus and two in the ovary. Clinically, both patients presented with nonspecific symptoms. The tumors were found at surgery, and confirmed as angiosarcomas on histologic examination. The ultrastructure of both tumors is also presented. The association with mucinous cystadenoma in the second tumor raises the possibility that this may be a mixed Mullerian tumor. Both tumors behaved in an aggressive fashion.

An evaluation of the computed tomographic scanner for the staging of carcinoma of the cervix.

Twenty patients with invasive carcinoma of the cervix (FIGO stages IB‐IV) were staged by routine pelvic examination, intravenous urography, chemistry studies, and barium enema. All patients received a CT scan of the abdomen and pelvis followed by pelvic examination under anesthesia (EUA). CT agreed with EUA staging in 13 of 20 patients (65%). All patients had surgical para‐aortic lymph node sampling. The sensitivity of CT for para‐aortic lymph node involvement was 67% and the specificity was 92%. CT scanning is equal to other clinical staging procedures for carcinoma of the cervix. It offers the advantages of being noninvasive and visualizing tumor for the construction of radiation portals. CT is useful in the detection of para‐aortic lymphadenopathy; however, the presence of normal sized or enlarged nodes makes pathologic examination, either by needle aspiration or surgery, necessary.

Parametrial implant in stage III B cancer of the cervix III. A five‐year study

Since 1975, the Department of Radiation Therapy, University of Maryland Hospital initiated a policy of supplementing the dose to the affected parametrium by using radium needles implants in conjunction with a protruding tandem preferably, or Manchester ovoid in the case of absence of the lower segment of the uterus. The authors have noted a remarkable improvement in local control as well as an improved three‐year survival rate with minimal immediate complications. Additional Stage IIIB (FIGO) cases were collected and they were treated by the same technique and have a close follow‐up since 1975. Forty‐nine cases studied, 32 (65%) survived with disease‐free status for a minimum of five years with no loss to follow‐up. Local control was excellent, as expected, at the level of 84% (41/49). There were 8% major complications as a consequence of radiation treatment and the majority of them required surgical intervention with excellent success. Paraaortic metastasis remains a major problem and requires further study. The current plan will include retroperitoneal exploratory laporatomy and para‐aortic node sampling with extension of the external beam portals to include the positive node region and followed by interstitial and intracavitary brachytherapy.

Radiation management of carcinoma of the tonsillar region

This is a retrospective analysis of 185 patients with squamous cell carcinoma of the tonsillar region treated at the Department of Radiation Oncology, University of Maryland Hospital from 1956 to 1977. All patients were treated by one of the following: (1) external beam therapy alone; or (2) combined external beam and interstitial brachytherapy. Five‐year disease‐free survivals, for early Stages (I and II), are 100% and 73%, comparable to the other series published in the literature. However, in advanced Stages III and IV, survival data showed 52% and 21%, respectively, 5‐year disease‐free survival better than any other reports. It is thought that the special interest of the authors in interstitial brachytherapy and a well‐integrated plan of external beam and brachytherapy is responsible for this success. The local control rate for T1, T2, T3, and T4 was 94%, 88%, 62%, and 19%, respectively, with the overall regional control rate of 83%. The prognostic factors appear to be related to the T‐factor, N‐factor, radiation dose, and method of treatment given, and the degree of tongue involvement. The detailed analysis of survivals and failures in the light of dosimetric study is presented along with some example cases of interstitial brachytherapy.

Management of adenoid cystic carcinoma of the uterine cervix (cylindroma): report of six cases and reappraisal of all cases reported in the medical literature.

We report 6 new cases of adenoid cystic carcinoma (cylindroma) of the uterine cervix (5, invasive cancer and 1, in situ cancer). All 6 patients were elderly women and 5 were hypertensive. Additionally, 3 (Patients 1, 2, and 4) were obese and 1 (Patient 3) had diabetes mellitus. Three patients were seen because of post‐menopausal vaginal bleeding and 3 were found to have malignant cells on routine exfoliative cytologic examination. Histologically, the tumor cells were relatively uniform, with scanty cytoplasms and a palisading pattern at the periphery of the tumor masses. Round cystic spaces were found in all 6 cases and hyaline nodules were present in some of the cystic spaces in 2. The tumors were found in Stages IA, IB, IIB, IIB, and IIIB (cases 1–4 and 6 respectively), and were treated with irradiation only. There have been only 38 cases of invasive adenoid cystic carcinoma of the cervix reported in the world medical literature. We review the treatment and survival for all 38 cases previously reported and add 5 new cases.

Radiation management of advanced nasopharyngeal cancer

During the period from 1957–1976, 70 patients with advanced malignant tumors of nasopharynx were treated by irradiation in the Department of Radiation Therapy, University of Maryland Hospital. Fortynine patients were treated with curative intent and 21 patients with palliative purpose. Of 49 patients treated for cure, 22 (45%) survived disease‐free for at least 5 years. Local control was achieved best (92%) by combined treatment, external beam and brachytherapy. Factors responsible for local control and disease‐free survival, appear to be related to clinical staging (primary and nodal disease), cell types and treatment used. In spite of aggressive radiation treatment for advanced cases (Stages III and IV), distant disease is still a major problem and will necessitate further trial by combined chemotherapeutic treatment with irradiation. This article highlights the results and failures of the technique of the irradiation, both external and brachytherapy. It is suggested that aggressive radiation treatment using a combined approach (external beam and brachytherapy, whenever possible) be done in all cases for cure. Palliative treatment can only offer a short‐term symptom‐free status in 72% of all cases treated.