Experience in the management of patients older than 80 years with vulval cancer.

INTRODUCTION: Vulval cancer is a disease of an increasing elderly population and consequently comorbidities are common. These conditions may preclude the application of standard therapy. OBJECTIVE: To review the outcome of women with vulval cancer older than 80 years comparing those who received recommended treatment (protocol-adherent) with those who did not (protocol-violated). METHODS: A retrospective chart review of a consecutive series of patients discussed over a 6-year period at our Multidisciplinary Team meeting. Treatment was deemed protocol-adherent if the Royal College of Obstetricians and Gynaecologists guidelines were followed and protocol-violated if not. Outcome data were retrieved from case notes, primary care input, cancer registry database, and reviewed in terms of survival and recurrence. RESULTS: Twenty-three cases of squamous cell carcinoma of the vulva were identified between 1999 and 2005 at Portsmouth Oncology Centre. Eight women were protocol-adherent and 15 women were not. Treatment decisions were made after individual discussion in conjunction with performance status. Protocol adherence was associated with a 25% recurrence rate and violation with a 53% recurrence rate. Median survival was shorter in the protocol-violated group compared with the adherent group (18 months vs 43.5 months respectively). CONCLUSION: These data imply that this issue arises not infrequently, perhaps every 3 to 4 months at each gynecological oncology Multidisciplinary Team meeting in the UK. The higher recurrence rate and shorter median survival among the protocol-violated group supports the validity of the current Royal College of Obstetricians and Gynaecologists treatment guidelines in this elderly age group. A prospective scoring system should be evolved to ensure a more objective approach to such patients with considerable co-morbidities.

Chemo-reirradiation in persistent/recurrent head and neck cancers.

BACKGROUND: This retrospective study was carried out to evaluate the feasibility and safety of chemo-reirradiation as a salvage treatment in patients with persistent/recurrent head and neck cancers. METHODS: From 1991 to 1999, records of 131 patients with head and neck carcinoma who had loco-regional persistent/recurrent disease following curative therapy were analyzed. Of these, 33 patients had received chemo-reirradiation. Four patients were further excluded as they had been reirradiated by brachytherapy or external radiotherapy alone. The remaining 29 patients received reirradiation along with chemotherapy. They were evaluated for toxicity profile, post-salvage survival and overall survival. RESULTS: The median reirradiation dose was 34 Gy (range, 12-50 Gy) and median cumulative RT dose was 104 Gy (range, 72-124 Gy). The median for chemotherapy cycles was four. Grade 2/3 mucositis, dermatitis, neutropenia were seen in 10%, 7% and 3% of patients, respectively. An overall response rate was seen in 83% of patients with complete response in 31%. All complete responders had received a cumulative RT dose of >/=100 Gy. Those patients who were initially treated by external radiation alone benefited with subsequent chemo-reirradiation with a complete response rate of 54%. The median post-salvage overall survival was 9 months with the 1- and 2-year survival rates being 41% and 12%, respectively. The post-salvage disease free survival (P = 0.01) and overall survival (P = 0.008) were also significantly better in patients who were treated initially by external radiotherapy alone. CONCLUSIONS: Chemo-reirradiation appears feasible and effective in patients treated previously with external radiotherapy but needs proper patient selection. Patients should be given optimum reirradiation dose, with cumulative doses of >/=100 Gy, along with chemotherapy. This study warrants the need for more prospective trials.

Loco-regional failures in head and neck cancer: can they be effectively salvaged by nonsurgical therapeutic modalities?

BACKGROUND: This retrospective study was carried out to ascertain the extent of efficacy of nonsurgical salvage modalities, mainly chemotherapy (CT) alone or chemoradiotherapy (CTRT), for loco-regional failures in head and neck cancer (HNC). METHODS: Between 1991 and 1999, 131 patients with HNC, mostly stages III and IV, who had loco-regional residual ( n = 78) or recurrent lesions ( n = 53) following curative therapy with either radiotherapy (RT), neoadjuvant CT (NACT) followed by RT, or concurrent CTRT were included in this analysis. Of these, 84 patients (residual, 58; recurrent, 26), did not receive any form of salvage therapy, while 47 had either CT alone ( n = 22) or CTRT ( n = 25). Endpoints evaluated were: loco-regional response (LRR), post-salvage survival (PS), overall survival (OS), and normal tissue acute and late morbidities. RESULTS: Salvage therapy enabled a LRR in 46.8% of the patients. Both OS and PS were also significantly better for those who received salvage therapy ( P < 0.001). CTRT appears to offer significantly better salvage than CT alone for all the evaluated endpoints. Multivariate analysis for LRR, PS, and OS consistently showed the salvage RT dose to be a significant predictor. Early and late effects of salvage therapy were not influenced by either the salvage or total RT doses. CONCLUSION: Loco-regional failures in advanced HNC can be effectively salvaged by CTRT to significantly prolong OS and PS. However, to achieve an optimum therapeutic ratio, the choice of drugs, their schedule, and the RT dose need to be defined through randomized trials.

Medulloblastomas: clinical profile, treatment techniques and outcome - an institutional experience.

The present series reports an audit on the patterns of presentation, radiation treatment techniques, failure pattern and outcome in the 36 patients treated at a single institution. Patients were accrued between October 1991 and September 1999. They underwent total or subtotal resection along with craniospinal irradiation. The dose to the cranium ranged from 30 to 43Gy (median- 36Gy), to the spine from 20 - 36Gy (median- 36Gy) and the posterior fossa boost, which was delivered in 32 cases, ranged from 14 to 24Gy (median -18Gy). Simulator film evaluation was carried out at the time of analysis based on the French Medulloblastoma Group guidelines, which revealed a significant under-dosage in the region of posterior fossa and cribriform plate in 27% and 19% respectively. Adjuvant chemotherapy was administered in 7 patients. Salvage treatment in the form of chemotherapy (5 cases) and re-irradiation (2 cases) were attempted but were ineffective. The overall survival (OS) and progression free survival (PFS) rates were 54% and 40% respectively, with the median being 75 and 29 months respectively. Amongst all the prognostic factors considered, on univariate analysis, duration of symptoms was significant for PFS with a trend towards significance for OS, while extent of debulking had a trend towards significance for PFS. No factor emerged significant on multivariate analysis.