Radical prostatectomy for cT3-4 disease: an evaluation of the pathological outcomes and patterns of care for adjuvant radiation in a national cohort.

OBJECTIVE: • To use the Surveillance, Epidemiology and End Results Database to evaluate the pathological outcomes for patients with clinically staged T3-4 disease who undergo radical prostatectomy and to analyze whether these patients are receiving adjuvant radiation. PATIENTS AND METHODS: • We identified patients who were clinically staged as having T3-4N0M0 prostate cancer and underwent radical prostatectomy between 2004 and 2006. Clinical data regarding preoperative prostate-specific antigen, as well as pathological Gleason score, were also collected. • Descriptive analyses were performed regarding the pathological extent of disease for these patients. • Logistic regression analysis was performed to identify unadjusted and adjusted predictors of radiation use for those with non-organ-confined disease or positive margins. RESULTS: • A total of 718 patients were identified. Of these, 10.2% had organ-confined disease (8.1% with negative margins and 2.1% with positive margins). The median number of lymph nodes removed was three, with 9.9% of patients having pathologically positive lymph nodes. • The clinical accuracy of staging was found to be 81.4% for T3a, 77.4% for T3b and 70.1% for T4. Of those who had non-organ-confined disease or positive margins pathologically, 21.1% received adjuvant radiation. Logistic regression analysis revealed that those with Gleason 8-10 disease were most likely to receive adjuvant radiation. CONCLUSIONS: • In this large series from a population-based cohort, clinical staging of T3-T4 disease was highly accurate in predicting pathological extent, with only 10.2% of patients found to have pathological T2 disease. • Most patients with confirmed pathological T3-T4 disease did not receive adjuvant radiation.

(18)F-fluorodeoxyglucose positron emission tomography-based assessment of local failure patterns in non-small-cell lung cancer treated with definitive radiotherapy.

PURPOSE: To assess the pattern of local failure using (18)F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) scans after radiotherapy (RT) in non-small-cell lung cancer (NSCLC) patients treated with definitive RT whose gross tumor volumes (GTVs) were defined with the aid of pre-RT PET data. METHOD AND MATERIALS: The data from 26 patients treated with involved-field RT who had local failure and a post-RT PET scan were analyzed. The patterns of failure were visually scored and defined as follows: (1) within the GTV/planning target volume (PTV); (2) within the GTV, PTV, and outward; (3) within the PTV and outward; and (4) outside the PTV. Local failure was also evaluated as originating from nodal areas vs. the primary tumor. RESULTS: We analyzed 34 lesions. All 26 patients had recurrence originating from their primary tumor. Of the 34 lesions, 8 (24%) were in nodal areas, 5 of which (63%) were marginal or geographic misses compared with only 1 (4%) of the 26 primary recurrences (p = 0.001). Of the eight primary tumors that had received a dose of <60 Gy, six (75%) had failure within the GTV and two (25%) at the GTV margin. At doses of > or = 60 Gy, 6 (33%) of 18 had failure within the GTV and 11 (61%) at the GTV margin, and 1 (6%) was a marginal miss (p < 0.05). CONCLUSION: At lower doses, the pattern of recurrences was mostly within the GTV, suggesting that the dose might have been a factor for tumor control. At greater doses, the treatment failures were mostly at the margin of the GTV. This suggests that visual incorporation of PET data for GTV delineation might be inadequate, and more sophisticated approaches of PET registration should be evaluated.

Intensity-modulated radiation therapy (IMRT) for inoperable non-small cell lung cancer: the Memorial Sloan-Kettering Cancer Center (MSKCC) experience.

INTRODUCTION: Intensity-modulated radiation therapy (IMRT) is an advanced treatment delivery technique that can improve the therapeutic dose ratio. Its use in the treatment of inoperable non-small cell lung cancer (NSCLC) has not been well studied. This report reviews our experience with IMRT for patients with inoperable NSCLC. METHODS AND MATERIALS: We performed a retrospective review of 55 patients with stage I-IIIB inoperable NSCLC treated with IMRT at our institution between 2001 and 2005. The study endpoints were toxicity, local control, and overall survival. RESULTS: With a median follow-up of 26 months, the 2-year local control and overall survival rates for stage I/II patients were 50% and 55%, respectively. For the stage III patients, 2-year local control and overall survival rates were 58% and 58%, respectively, with a median survival time of 25 months. Six patients (11%) experienced grade 3 acute pulmonary toxicity. There were no acute treatment-related deaths. Two patients (4%) had grade 3 or worse late treatment-related pulmonary toxicity. CONCLUSIONS: IMRT treatment resulted in promising outcomes for inoperable NSCLC patients.

A population-based comparison of overall and disease-specific survival following local excision or abdominoperineal resection for stage I rectal adenocarcinoma.

PURPOSE: The use of local excision (LE) for early stage rectal adenocarcinoma is increasing due to the associated morbidity of radical resection. To determine if survival in stage I rectal cancer differs following LE or abdominoperineal resection (APR), we analyzed the Surveillance, Epidemiology, and End Results Database. MATERIAL AND METHODS: We selected patients diagnosed between 1988 and 2002 with T1-2N0M0 rectal adenocarcinoma measuring ≤4 cm who underwent either local excision with (LE + RT) or without adjuvant radiation (LE alone) or APR alone. Overall survival (OS) and disease-specific survival (DSS) curves were calculated using the Kaplan-Meier method. Univariate and multivariate Cox regression was also performed to determine the effect of covariates on OS and DSS. RESULTS: A total of 2,391 patients were identified including 981 (41 %) treated with APR, 1,018 (43 %) treated with LE alone, and 392 (16 %) treated with LE + RT. With a median follow-up of 69 months, there was no difference in OS or DSS seen between the three groups (p > 0.05 for all comparisons). When stratifying by T-stage, there was a significant difference in overall survival between LE alone and APR for T2 disease. However, there was no difference in DSS between these two subgroups. There were no other significant survival differences between all comparable subgroups. CONCLUSIONS: In this large population-based study, there was no difference in long-term DSS between patients who underwent an APR compared to selected patients who underwent LE with or without adjuvant radiation. Although these data further reinforce the promising data regarding the selected use of LE, further prospective studies are needed to further elucidate the role of LE in this setting.

Involved-field radiation therapy for inoperable non small-cell lung cancer.

PURPOSE: Dose escalation has been shown to improve local control in non-small-cell lung cancer (NSCLC) treated with definitive radiation therapy, but with increased complications. We implemented the use of involved-field radiotherapy (IFRT) in an effort to reduce toxicity while treating the gross tumor to higher doses. This analysis reports failure rates in uninvolved nodal regions with the use of IFRT. PATIENTS AND METHODS: A total of 524 patients with NSCLC treated with three-dimensional conformal radiotherapy at Memorial Sloan-Kettering Cancer Center between 1991 and 2005 were reviewed. Only lymph node regions initially involved with tumor by either biopsy or radiographic criteria were included in the clinical target volume. Elective nodal failure (ENF) was defined as a recurrence in an initially uninvolved lymph node in the absence of local failure. RESULTS: Only 32 patients (6.1%) with ENF were identified. The 2-year actuarial rates of elective nodal control and primary tumor control were 92.4% and 51%, respectively, with a median follow-up of 41 months in survivors. In patients who achieved local disease control, the 2-year elective nodal control rate was 91%. The median time to ENF was 6 months (range, 0 to 56 months). Many patients experienced treatment failure in multiple lymph node regions simultaneously. CONCLUSION: The use of IFRT did not cause a significant amount of failure in lymph node regions not included in the tumor volume. Therefore, IFRT remains an acceptable method of treatment that allows for dose escalation while minimizing toxicity.

High-dose radiotherapy for the treatment of inoperable non-small cell lung cancer.

PURPOSE: Local failure continues to be a major cause of mortality in patients with inoperable non-small cell lung cancer (NSCLC) treated with radiation therapy. Dose escalation is one method of improving local control. We investigated whether high-dose radiotherapy enhances outcomes in patients with inoperable NSCLC. MATERIALS AND METHODS: Eighty-two patients with inoperable NSCLC stage I-IIIB were treated with three-dimensional conformal radiotherapy to doses of > or =80 Gy. Patients were divided into 2 groups based on stage: those with stage I/II disease (55 patients) and those with stage III (IIIA or IIIB) disease (27 patients). RESULTS: The 5-year local control and overall survival rates for the patients with stage I/II disease were 67% and 36%, respectively, with a median survival time of 41 months. For the patients with stage III disease, 5-year local control and overall survival rates were observed to be 39% and 31%, respectively, with a median survival time of 32 months. CONCLUSIONS: Our data show a favorable 5-year overall survival rate (36%) with an acceptable toxicity profile in patients with early-stage NSCLC treated to doses of > or =80 Gy using three-dimensional conformal radiotherapy. Sequential chemotherapy combined with high-dose radiation gave survival rates equivalent to those seen with concurrent chemoradiation therapy in locally advanced disease. The overall survival and local control rates observed among patients with all stages of disease are consistent with and comparable to results from other dose-escalation studies reported in the literature.