William A. Raub

Quality of Life: Radical Prostatectomy Versus Radiation Therapy for Prostate Cancer

PURPOSE The impact of radical prostatectomy and external beam radiotherapy on the quality of life of patients was compared. MATERIALS AND METHODS A total of 136 patients underwent radical prostatectomy and 60 underwent external beam radiotherapy for clinically localized prostate cancer. Patients were asked to complete a questionnaire containing The Functional Living Index: Cancer, the Profile of Moods States, and a series of questions evaluating bladder, bowel and sexual function. RESULTS The radical prostatectomy group had worse sexual function and urinary incontinence, while the external beam radiotherapy group had worse bowel function. Of the patients 90% from both groups stated that they would undergo the treatment again. CONCLUSIONS Radical prostatectomy and external beam radiotherapy have comparable impact upon quality of life.

New strategies are needed in diffuse malignant mesothelioma

Background. Medical records of 50 patients with malignant mesothelioma were reviewed to determine the clinical features and factors influencing survival.

Radical resection of periampullary tumors in the elderly: evaluation of long-term results.

Increasingly, patients of advanced age are coming for evaluation of periampullary tumors. Although several studies have demonstrated the safety of resecting periampullary tumors in older patients, few long-term survival data have been reported. Between 1983 and 1992 various periampullary masses were resected in 70 patients over age 65 (range 65–87 years). Total pancreatectomy was performed in 11 patients, and 59 patients underwent pancreaticoduodenectomy. The mean duration of hospitalization was 17 ± 15 days. Major complications occurred in 27 patients (39%), and operative mortality rate was 8.5%. Overall median survival was 24 months; and 5-year survival was 25%. Perioperative outcome was compared in patients aged 65 to 74 years and in patients ≥75 years old. The older age group required longer periods in the surgical intensive care unit postoperatively, but the long-term survival was similar in the two age groups. Radical resection with the intent to cure periampullary tumors is safe in selected patients of advanced age, and long-term survival is in the range of expected survival for younger patients with the same tumors.

A phase II trial of neoadjuvant methotrexate, vinblastine, doxorubicin, and cisplatin in the treatment of patients with locally advanced breast carcinoma

Traditionally, primary surgical therapy is considered unsuitable for the treatment of patients with locally advanced breast carcinoma (LABC). Multiple reports have documented the efficacy of primary chemotherapy in this group of patients. The purpose of this study was to investigate the efficacy of a multimodality treatment program in reducing distant and local disease relapses in patients with LABC.

Hyperfractionated radiation therapy and 5-fluorouracil, cisplatin, and mitomycin-C (+/- granulocyte-colony stimulating factor) in the treatment of patients with locally advanced head and neck carcinoma.

The authors had previously reported preliminary results of a treatment regimen of concurrent hyperfractionated radiation therapy and chemotherapy in patients with locally advanced head and neck carcinoma that demonstrated both feasibility and high local control. In an attempt to reduce acute mucosal and hematologic toxicity, granulocyte‐colony stimulating factor (G‐CSF) was added during the second phase of this study.

Prognostic factors in lung cancer based on multivariate analysis

Multivariate analysis was performed on 1,336 patients with lung cancer to determine the prognostic significance of stage, race, gender, age, and treatment in each histologic subtype. The study was designed to establish a subgroup of patients whose survival outcome might be better, based on these factors. On univariate analysis, stage and surgery were significant factors in each histologic subtype. The presence of liver metastases, was an important prognostic factor in all subtypes except large cell carcinoma. However, 131 of 140 patients with large cell carcinoma had liver metastases, and this factor may account for the observation that liver metastases was not a significant prognostic factor. In the multivariate analysis, good prognosis was associated with early stage disease and surgical treatment in all cell types. For a given stage, the improvements in relative risk due to surgery represent both the effect of treatment and the effects of other unmeasured patient characteristics, such as performance status and physiological status, that make the patient a suitable candidate for surgery.

Lung cancer in patients with human immunodeficiency virus infection

This retrospective study determined the clinical course of lung cancer in patients with human immunodeficiency virus (HIV) infection. A total of 23 patients with HIV infection archived as lung cancer were studied: 16 were identified from about 1,000 lung cancer patients entered in the tumor registry and medical records of Jackson Memorial Hospital, 7 were identified from about 1,000 HIV-positive patients entered in the Special Immunology registry of Veterans Administration Medical Center, 4 patients did not have pathologic confirmation of lung cancer, and 19 patients, all men, met the criteria for analysis (histopathologic diagnosis of lung cancer and HIV+ by serology). The median age was 47 (range: 36–66). Risk factors for HIV were homosexuality (6 patients), blood transfusion (3), promiscuity (5), intravenous drug abuse (4), and none (3). Six patients had a history of coexistent pulmonary tuberculosis and 5 had Pneumocystis carinii pneumonia. Median survival from diagnosis of lung cancer was 3 months. Advanced stages of both HIV infection and lung cancer may account for the poor survival. All patients were men and noted to be younger than other patients with lung cancer.

The role of hyperfractionated re-irradiation in metastatic brain disease: A single institutional trial

Progression of brain metastases after brain irradiation has prompted several studies on retreatment of the brain. Increased durations of survival and improved quality of life have been reported. Fifteen patients with previously treated brain metastases were entered into this pilot study between May 1990 and January 1994. All patients had neurologic and/or radiologic evidence of progression of brain metastases. The lung was the primary site in 60% of cases. The remaining 40% had breast, ovarian, and skin primaries. The median interval between the first treatment and retreatment was 10 months. All patients received whole-brain irradiation with or without a boost for their initial treatment course. Doses ranged from 3,000 to 5,500 cGy for initial treatments (median, 3,000). Retreatment consisted of limited fields with a median side equivalent square of 8.8 cm. Patients were retreated with a median dose of 3,000 cGy (range, 600-3,000 cGy). A median cumulative dose of 6,000 cGy was achieved. Retreatment consisted of twice-daily fractions (150 cGy/fraction). Retreatment was tolerated without serious complications. Of the 15 patients treated, nine (60%) experienced improvement, and five (27%) had stabilization of neurologic function and/or radiographic parameters. Median survival was 3.2 months; two of the reirradiated patients survived > or = 9 months. In conclusion, reirradiation is a viable option in patients with recurrent metastatic lesions of the brain, and the use of a limited retreatment volume makes this a well-tolerated, low-morbidity treatment that leads to clinical benefits and, in some instances, enhanced survival. The influence of hyperfractionation on the outcome needs to be investigated further in large series.

High-dose-rate remote afterloading intracavitary brachytherapy for the treatment of extrahepatic biliary duct carcinoma.

PURPOSEThe purpose of this study was to determine whether a dose response exists for extrahepatic bile duct carcinoma (EBDC) when treated with increasingly higher radiation doses delivered via a combination of external beam radiation (EBRT) and high dose rate intracavitary brachytherapy (HDRIB). To establish the best tolerated dose of HDRIB. METHODS AND MATERIALSEighteen patients with pathologically proven, locoregional but unresectable or incompletely resected EBDC were studied from 1991–1998 in this phase I/II trial. All patients received EBRT, delivered via megavoltage photons at standard fractionation schedules, for a total dose of 45 Gy. The HDRIB was delivered using the nucleotron HDR remote afterloading unit with a 10 Ci Ir192 source. Each treatment of HDRIB delivered 7 Gy at 1 cm depth. The first group of eight patients received one treatment of HDRIB (Group 1, total dose = 52 Gy). The second group of six patients received two weekly treatments (Group 2, total dose = 59 Gy). The last group of four patients received three weekly treatments of HDRIB (Group 3, total dose = 66 Gy). HDRIB was delivered once weekly concomitant with the EBRT. Acute adverse reactions were evaluated after for each group of patients before escalating to the next higher dose level of HDRIB. RESULTSThe median follow up time for all 18 patients was 15 months. The median survival for all 18 patients was 12.2 months (range 2 to 79.6 months). Overall two-year survival was 27.8%. Three patients (16.7%) had survival of more than 5 years. Dose response is suggested by the median survival of the three groups (9, 12.2, and 20.3 months for Group 1, 2, and 3, respectively), although this did not reach statistical significance. Complete or partial response (>50% reduction in tumor size) was seen in 25% of patients receiving total of 52 Gy compared to 80% of patients (5 patients in Group 2 and 3 patients in Group 3) receiving greater than 59 Gy (P = 0.05). No patients developed Grade 4 complications. One patient in Group 2 developed Grade 3 toxicity after second treatment of HDRIB. CONCLUSIONHigh dose rate brachytherapy of 21 Gy in three divided weekly treatments, plus 45 Gy of external beam radiation is well tolerated. A dose response is shown with significant increase of PR and CR rate for dose >59 Gy. This modality of treatment appears to be safe and effective for inoperable extrahepatic biliary duct carcinoma.

Prognostic factors and survival in patients with spinal cord gliomas after radiation therapy.

The purpose of this study was to determine the impact of various prognostic factors on survival in spinal cord gliomas treated with radiation. Fifty-three patients with spinal cord gliomas irradiated at three major institutions were studied. Fifty-one patients were classified as having ependymoma, astrocytoma, or both. Two patients were classified as having gliomas (otherwise unspecified). Eleven patients had complete resection of their tumor. Biopsy or partial resection was done in the remaining patients. All patients received external beam radiation. Information on these patients was placed in a central database file and analyzed for the effect of several prognostic factors on survival. Overall survival of the entire group was 76.9% and 61.5% at 5 and 10 years, respectively. Pathologic status significantly affected survival (p = 0.03). Patients with ependymomas had a 5-year survival of 93.8% and a 10-year survival of 67.5%. Patients with astrocytoma had a 5-year survival of 64.2% and a 10-year survival of 54%. Univariate analysis showed pathology and the presence of cysts (p = 0.038) to significantly affect survival. Age, sex, location of the primary, extent of surgery radiation dose, and number of involved segments did not affect survival. On multivariate analysis, astrocytic pathology, involvement of more than five segments, male sex, and the absence of cysts (in or adjacent to the tumor) were associated with a significantly inferior survival. This study confirms the importance of pathology and number of segments involved in determining outcome or survival. The presence of cysts adjacent to or within the tumor was found to be associated with an improvement in survival.