William M. Wisbeck

Adenocarcinoma of the proximal colon sites of initial dissemination and patterns of recurrence following surgery alone

Seven hundred ninety‐five patients were adenocarcinomas of the proximal colon were reviewed. Two hundred forty‐five patients presented with disseminated disease at the time of diagnosis, and were analyzed to identify mechanisms and sites of disease spread. Five hundred fifty patients underwent radical resection, and were followed for a minimum of 48 months or until time of documented relapse. One hundred eightysix patients (34%) manifested recurrent carcinoma, 64 (34.5%) of whom underwent second laparotomy at the time of initial recurrence. In 139 patients (74.5%), the distribution of clinical recurrence was confined to the abdomen, retroperitoneum, and liver. Prognostic influence of initial stage and tumor grade are analyzed, and possible implications for surgical staging and adjuvant therapy are discussed.

Adenocarcinoma of the stomach: Autopsy observations with therapeutic implications for the radiation oncologist

Autopsy and clinical records of 85 patients dying of stomach cancer were reviewed in order to study patterns of recurrence and dissemination. Loco-regional recurrence was observed in 15 of 16 patients who had undergone potentially curative surgical resection, and was the most common form of treatment failure. Peritoneal seeding, seen in 29% of the patients who died without treatment, was the most common manifestation of cancer dissemination (47%), and was associated with shorter average duration of survival. Among patients undergoing potentially curative resection, initial serosal involvement was predictive of subsequent peritoneal recurrence (7/10), whereas only 1 of 6 patients with initially uninvolved serosa developed this pattern of failure. Patients with primary cancers involving the gastro-esophageal junction were more likely to have extra-abdominal spread (9/13, 69%) than patients whose cancers involved more distal portions of the stomach (35/72, 49%). Potential implications for surgical staging, choice of radiation treatment volume, and design of clinical trials are discussed.

The role of postoperative irradiation in the treatment of oligodendroglioma.

PURPOSE Controversy regarding the role of adjuvant radiation therapy for the treatment of oligodendroglioma continues to exist. To better define the utility of postoperative irradiation for this tumor, the experience at the University of Washington was retrospectively examined. METHODS AND MATERIALS The histologic samples of 63 patients given the diagnosis of oligodendroglioma were reviewed by a panel of neuropathologists and 41 were classified as pure oligodendroglioma. The two treatment groups included 14 patients treated with surgery only and 27 who received surgery and postoperative radiation and were analyzed using univariate and multivariate analysis with respect to prognostic factors, freedom from relapse, and survival. RESULTS Univariate statistical analysis of 14 clinical variables showed that a poorer prognosis was associated in patients with high cell density (p = .008), necrosis (p = .017), hemiparesis (p = .026), and papilledema (p = .091), while patients presenting with seizures had a better prognosis (p = .0096). Multivariate analysis showed necrosis (p = .001) and hemiparesis (p = .02) to be associated with decreased survival. Multivariate and univariate analysis of the treatment groups found them to be homogenous with respect to prognostic factors. Survival times were significantly longer in the group treated with postoperative irradiation (median survival time 84 vs. 47 months, p = .032). The 5 and 10 year survival rates were 83% and 46%, respectively, for the irradiated patients compared with 51% and 36% for those treated with surgery alone. Freedom from tumor recurrence times were also longer in irradiated patients (median relapse free time 79 vs. 42 months, p = .01). CONCLUSION Based on the results of this study, we recommend continuing the practice of treating oligodendroglioma with postresection irradiation until a prospective multicenter clinical trial is conducted to thoroughly evaluate the role of postoperative irradiation in the treatment of this tumor.

Adenocarcinoma of the colon an autopsy study with implications for new therapeutic strategies

Clinical, pathologic, and autopsy records of 53 patients who had localized adenocarcinoma of the proximal colon and had undergone potentially curative surgery were analyzed to define ultimate patterns of recurrence and final patterns of dissemination. Ten patients (19%) died with locoregional recurrence alone (operative bed and retroperitoneal nodes). Liver metastases were present in 31 patients, accompanied by other sites of infradiaphragmatic failure in 29 patients (94%). Twenty‐three patients (43%) died with cancer confined to the abdomen, retroperitoneum, and liver. The distribution of involved sites points to potential refinements in the surgical staging of this cancer and suggests a rational strategy for planning adjuvant therapy designed to address all the principal early mechanisms of disease dissemination.

Second laparotomy for proximal colon cancer: Sites of recurrence and implications for adjuvant therapy

Sixty-four patients with primary adenocarcinomas of the colon proximal to the peritoneal reflection underwent exploratory laparotomy at the time of first recurrence of their cancers. Local recurrence, retroperitoneal lymph node metastases, parenchymal liver metastases, and diffuse peritoneal seeding were identified as frequent components of the overall pattern of recurrence. The significance of these findings has been discussed herein, relative to refinements of operative technique and selection of appropriate adjuvant therapy.

Adenocarcinoma of the retroperitoneal ascending and descending colon: Sites of initial dissemination and clinical patterns of recurrence following surgery alone

One hundred twenty-seven patients with previously untreated primary carcinomas of proximal, retroperitoneal large bowel were retrospectively analyzed. Sites of involvement in 33 patients with surgically incurable (disseminated) disease were analyzed to define patterns of initial spread. Ninety-four patients were analyzed following attempted curative resection to determine anatomical distribution of initial clinical recurrences. Thirty-one patients recurred (33%). Twenty-four of these patients (77.5%) demonstrated an initial pattern of relapse clinically confined to the abdomen and retroperitoneum. Analysis was performed to identify factors of prognostic significance. Implications for adjuvant therapy are discussed.

Radiotherapy for locally recurrent infantile pancreatic carcinoma (pancreatoblastoma).

The authors report a case of recurrent paacreatoblastoma in a 3‐year‐old girl who was successfully treated with radiotherapy. The patient had two local tumor recurrences before radiation treatment; the second recurrence was managed with radiation alone. Computerized tomography scan at the completion of radiotherapy showed dramatic tumor regression. Six weeks after radiotherapy was finished exploratory laparotomy was performed; multiple biopsies showed no evidence of tumor. The patient is currently disease‐free 2 years after completion of radiotherapy. This case suggests a role for radiation therapy in the management of children with paacreatoblastoma.

Adenocarcinoma of the cecum: Natural history and clinical patterns of recurrence following radical surgery

One hundred and forty-three patients with previously untreated primary adenocarcinomas of the cecum were analyzed. Fifty-three patients manifesting disseminated disease at diagnosis were analyzed to define mechanisms of disease spread. Ninety patients were analyzed following attempted curative resection to determine anatomical distribution of initial clinical recurrences. Twenty-eight patients recurred (31%), of whom 9 underwent a second laparotomy. Nineteen of the 28 patients who recurred (68%) demonstrated an initial pattern of relapse clinically confined to the abdomen, liver, and retroperitoneum. Analysis was performed to determine the influence of stage and grade of the primary tumor on prognosis. Implications for adjuvant therapy are discussed.

Multi-institutional, randomized, double-blind, placebo-controlled trial to assess the efficacy of a mucoadhesive hydrogel (MuGard) in mitigating oral mucositis symptoms in patients being treated with chemoradiation therapy for cancers of the head and neck

The objective of this trial was to determine how a mucoadhesive hydrogel (MuGard), a marketed medical device, would fare when tested with the strictness of a conventional multi‐institutional, double‐blind, randomized, placebo‐controlled study format.

Improved localization of infratentorial ependymoma by magnetic resonance imaging: Implications for radiation treatment planning

Ependymomas of the posterior fossa extend into the upper cervical spinal cord in approximately one-third of cases. Unfortunately, the posterior fossa and upper cervical cord region is often poorly seen on computed tomography (CT), making radiotherapy planning difficult. We report five cases of posterior fossa ependymoma with extension into the cervical cord where magnetic resonance imaging (MRI) demonstrated the caudal extent of tumor more clearly than CT. The extent of tumor depicted by MRI in each case correlated well with the operative findings. Higher doses of radiotherapy to the entire tumor volume are associated with improved survival in infratentorial ependymoma; however, the radiation tolerance of the cervical spinal cord is close to the dose necessary to control posterior fossa ependymoma, making limitation of radiation field volumes important. MRI may provide a method of precisely defining caudal tumor extent of posterior fossa ependymomas so that limited volume, high dose radiotherapy can be more safely administered to these patients.