William O. Russell

Sarcoma of soft tissue: Clinical and histopathologic parameters and response to treatment

Radical dose radiation therapy alone or combined with limited surgery has been employed in the management of 100 patients with primary (71) and recurrent (29) sarcoma of soft tissue. Results of this experience show that a combination of conservative surgery and radiation therapy, based upon radical dose levels and sophisticated techniques, is effective: only 13 of 100 patients showed local regrowth during a followup of 2–12 years. This may be compared with an expected ⩽25 recurrences had treatment been radical surgery (wide resection or amputation). For lesions located on the distal extremities (elbow‐hand, knee‐foot) there were local failures in only 3 of 59 (5%). Further, 75% of patients treated by the improved techniques utilized in the recent 8 years retained a useful limb which is free of pain or edema. Histopathologic grade is demonstrated to be an important indicator of prognosis of local recurrence and of disease‐free survival. Local recurrence rates were 0/23, 9/53, and 4/24 for Grades 1, 2, and 3. Disease‐free survival rates were 19/23 (86%), 27/53 (51%), and 4/24 (17%) for Grades 1, 2, and 3, respectively. Invasion of skin appeared to be a sign of poor prognosis; 8 of 9 such patients developed distant metastases.

Management of patients with sarcoma of soft tissue in an extremity

Results of management of 57 patients with sarcoma of soft tissue on an extremity by radical dose radiation therapy are presented. These patients had been treated 2 to 10 years previously at the University of Texas M.D. Anderson Hospital. Forty‐six patients were seen after simple excision (no palpable tumor at time of our examination), while 11 patients were treated for the primary or a recurrent tumor. The recommended surgical treatment was amputation in all patients of this study sample. Radiation therapy technique was complex; dose level was 6300–7000 rads or the equivalent in 61/2‐7 weeks. Local control has been achieved in 50 of 57 patients. For the 46 patients with lesions in the elbow‐hand or knee‐foot regions, local control has been 100%. In contrast, 7 of 11 tumors located in the proximal extremities (upper arm or thigh) have recurred locally. A useful limb has been retained for 2 to 10 years in 34 of the cases. The more refined techniques of therapy now being employed yield a good functional result in nearly all cases. Metastasis‐free survival at 2 to 10 years is 58%. This figure depends not only upon histologic type but apparently also on histologic grade: 26 of 36 (72%) for Grades 1 and 2 but only 7 of 17 (41%) for Grade 3.

Recurrence-free survival time for surgically treated soft tissue sarcoma patients. Multivariate analysis of five prognostic factors.

A staging system, based upon the experience of 1215 patients, was published by the American Joint Committee Task Force on Soft Tissue Sarcoma in 1977. A subset of these patients, 594, was selected to study recurrence‐free survival time. The authors found 331 patients with a recurrence within 5 years (100 local only, 123 metastatic only, and 108 local + metastatic); median months to recurrence was 9.7. Within 5 years, recurrence was clearly associated with mortality: among the 331 patients who experienced a recurrence, 245 died, whereas only 31 died among the 263 who had no recurrence. To further evaluate the utility of the published staging system, a multivariate analysis of five factors was carried out for 297 of the 594 patients (patients with unknown information for any one of these factors were excluded). Factors in addition to grade that exerted a significant influence on recurrence were: direct extension, symptoms, and location of tumor when survival was measured to the first of any recurrence, and tumor size, measuring survival to the first metastatic recurrence. It is therefore recommended that these factors be taken into account in staging this disease. Estimates of probable recurrence‐free survival time based upon the multivariate model (Weibull) are also presented.

Follow-up study of thyroid cancer treated by unilateral lobectomy

c oNsr~~n4nLE uncertainty persists concerning what constitutes adequate surgical resection for differentiated carcinoma of the thyroid gland. The present discussion will be limited to the problem of surgery of the thyroid gland itself, when cancer is found grossly involving only one lobe. In recent years, the trend has been toward more extensive resection of the thyroid gland. With rare exceptions [l-3] genera1 agreement has come that anything less than total lobectomy is inadequate and not curative in this situation, because of the high incidence of residual cancer (20 per cent) found on completing the Iobectomy [4] or of stump recurrence [s;]. Beyond this point, authoritative opinion is divided among those who advocate only total lobectomy with or without resection of the isthmus [6,7], those who advocate total Iobectomy plus resection of some portion of the opposite lobe [4,8], and those who advocate total thyroidectomy [9-201. Support for use of the more extensive procedures has come from the observation of intragIandular spread or “muIticentric involvement” by cancer, reported after routine surgical pathologic examination as I I to 30 per cent involvement of the opposite lobe [8,9,12-r4,18,19,21,22]. Crile [7], however, takes the position that “the mere presence of isoIated microfoci of cancer in a lobe of the thyroid does not necessariIy mean that cancer will develop cIinicaIIy.” For the past twelve years at The University of Texas M. D. Anderson Hospital and Tumor Institute, we have been engaged in evaIuating the adequacy of these primary surgical procedures for carcinoma of the thyroid gIand. Prior to rgfo, at this institution, total lobectomy on the involved side, with or without neck dissection, was considered adequate therapy whenever there was no gross involvement of the opposite lobe. Later, when total thyroid gland resections were performed to facilitate radioiodine therapy of metastatic thyroid cancer, a significant incidence of cancer in the contraIatera1 Iobe was observed. This cast doubt on the adequacy of tota unilateral lobectomy as a curative procedure. As a result, a program for evaluating the problem was initiated whereby patients who had undergone previous “curative” lobectomy would either be submitted to prophyIactic resection of the remaining lobe or would be observed clinically on a long-term basis. A third group of patients would be treated by tota thyroidectomy as the initial surgical procedure or following previous thyroid biopsy or partial lobectomy. A corolIary project was undertaken to study the resected gland, whenever possible, by subseria1 whoIe organ sections in order to determine the mode of intraglandular dissemination and the true incidence of contralateral lobe involvement. Previous communications from this institution [g,23] have reported this dissemination to the opposite lobe in 30 per cent of glands examined by routine pathologic technics and in 84 per cent of glands submitted to subseria1 whole organ study. The present report concerns that group of patients with thyroid cancer whose initial surgical management was total lobectomy with or without neck dissection. This was then folIowed either by immediate prophylactic

Soft part tumors

Results of management of rhabdomyosarcoma of childhood have improved in a dramatic manner during the recent 10 years as a consequence of the treatment by a three modality approach which relies on an intensive multi‐drug multicycle chemotherapy regimen combined with radiation therapy and or surgery. Both local results and total disease‐free survival rates are markedly better with this more comprehensive approach. A staging system for sarcoma of soft tissue has just been developed by the A.J.C. Histopathological grade is the important parameter: stage 1, 2, and 3 are tumors of histological grades 1, 2, and 3 respectively (an outline of the system is presented). Treatment results of 100 patients with sarcoma of soft tissue (extremities 89, torso 11) treated by radical dose radiation therapy (>6300 rad) and limited surgery at M. D. Anderson Hospital are presented. For both local control and disease free survival, results decreased with advancing stage and anatomic site was not a factor per se. Radiation therapy under tourniquet induced hypoxia was not found to be significantly more effective than conventional radical dose therapy. The necessity of planning treatment such that if subsequent surgery is required, the fields will provide the best distribution of unirradiated or low dose tissue for preparation of flaps, etc.

Revision of the clinical staging system for cancer of the larynx

The system for classification of laryngeal cancer was revised following a field study of 19 participating cancer clinics and hospitals in the United States and the T.N.M. Committee of the U.I.C.C. Study of records of 1,645 larynx cancer patients demonstrated that the best survival was experienced by patients with in‐situ carcinoma (Tis), 97%. When the tumor was limited to the region of origin (T1), survival was 94% for glottic cancers and 91% for supraglottic cases. As the tumor spread to other regions of the larynx but still confined to the larynx without fixation (T2), survival was 85%–82%; when the larynx was fixed, and tumor still confined to the larynx (T3), survival was 65%–74%, and as the tumor spread outside the larynx (T4) survival dropped to 40%–55%. When cervical lymph node metastases were not fixed, survival was ±50% (hemolateral, bilateral, or contralateral non‐fixed metastases). When the regional metastases were fixed, survival dropped to 21%. There were no survivors when the metastases were bilateral and fixed. Grouping the 4 “T”, 4 “N”, and 2 “M” categories into four stages, survival progressively decreased from 94% for Stage I, 85% for Stage II, 59% for Stage III, and 9% for Stage IV for the glottic cases. Similar survival for the supraglottic group was 91%, 82%, 49%, and 9%.