[Restaging brain computerized tomography after treatment of non-operable lung neoplasms]. / La tomografia computerizzata dell'encefalo nella ristadiazione dopo terapia delle neoplasie polmonari non suscettibili di trattamento chirurgico.

PURPOSE: To assess the role of CT brain scans as a routine restaging procedure after primary, aggressive, drug or radiation therapy of unresectable lung cancer. If early, asymptomatic brain metastases are detected and treated, survival could be improved relative to the patients showing brain involvement in a later CT scan performed during the follow-up, at the onset of neurological symptoms. MATERIAL AND METHODS: One hundred patients affected with lung cancer, unresectable on account of histology (small-cell carcinoma) or advanced stage (III, IV) were submitted to chemo- and/or radiotherapy, after a clinical staging including brain CT, which was negative in all patients. Brain CT was also repeated at the end of therapy (restaging), in the absence of any neurological symptom. Further scans were obtained during the subsequent follow-up only when clinical symptoms occurred, suggesting metastases to the brain. Survival values were analyzed in the patients whose brain involvement was detected during restaging, vs those showing symptomatic brain metastases during the follow-up. RESULTS: Only 4 patients had asymptomatic metastases, diagnosed with the restaging brain CT scan. Their survival rate was significantly lower than that of the 20 patients whose brain involvement was shown by a follow-up CT scan, performed after the onset of neurological symptoms. However, death was rarely a consequence of brain metastases: primary or other metastatic sites were involved in the terminal events, in the greatest majority of these cases. DISCUSSION AND CONCLUSIONS: The sudden, asymptomatic brain involvement, detected at restaging CT scan after primary therapy for unresectable lung cancer, does not correlate with a better prognosis than symptomatic metastases, diagnosed later with a follow-up CT obtained performed for clinical suspicion. Therefore the use of restaging CT scan is not warranted, as a routine procedure, except for the clinical trials intended to define optimal treatment schedules.

[Combined chemo-radiotherapy in non-operable cervico-facial neoplasms. Final results of an experience with non-selected patients]. / Integrazione chemio-radioterapica nelle neoplasie cervico-facciali inoperabili. Risultati definitivi di una esperienza su pazienti non selezionati.

The management of advanced inoperable head and neck cancer is often based on a combined chemo-radiotherapy approach. No definitive conclusions on the effectiveness of this combination can be drawn from clinical trials because these neoplasms are heterogeneous and treatment schedules vary. Many scientific trials test highly toxic combinations, whereas not only good results but also low toxicity are mandatory in the current practice. We report the results obtained in 90 consecutive patients affected with inoperable head and neck cancers in stages III-IV, or relapsed after surgery. Chemotherapy consisted of a cis-platinum/bleomycin induction phase, followed by weekly administrations of cis-platinum simultaneous with conventional irradiation. The objective remission rates, achieved at the end of the induction chemotherapy and the simultaneous chemo-radiotherapy phases, were respectively 55.5% and 84.5%. The tumor disappeared in 39% of cases, by the end of the whole treatment. With the Kaplan-Meier method, 3-year overall, progression-free and relapse-free survival rates were 21.20%, 22.25% and 38.75%, respectively. The overall survival rate, calculated with the "log-rank" test according to the stage and the site of the primary tumor, exhibited no significant differences. In contrast, significant differences (p < 0.05) were demonstrated, according to treatment intent (curative radical: 26%, vs palliative: 0%) and to the achievement of an objective response at the end of induction chemotherapy--i.e., 48% 3-year survival rate, vs 7% in chemotherapy resistant cancer patients. When limiting the analysis to 72 radically irradiated patients, however, the achievement of CR after induction chemotherapy lost its prognostic value. Toxicity was not substantially higher than with conventional irradiation. Our results are in agreement with literature data on this subject which, regarding survival, fail to prove such integrated treatments as ours better than irradiation alone. In contrast, the preliminary combination of chemotherapy and irradiation is clearly better for the patients waiting to receive radiation therapy, because tumor volume and related symptoms markedly decrease after induction chemotherapy. Currently the best survival rates (about 50% at 3 years) with chemo-radiotherapy are obtained, in this kind of cancer, by combining cis-platinum and continuous-infusion 5-fluorouracil, simultaneous with irradiation. However, frequent and severe toxicity is reported. Should such a modality be adopted in the current practice, patients should be selected according to their medical conditions.

[Radiotherapy of limited pulmonary microcytoma in current clinical practice]. / La radioterapia del microcitoma polmonare "limitato" nella pratica clinica corrente.

The use of thoracic irradiation in the treatment of "limited disease" small-cell lung cancer yields better local control and survival rates than chemotherapy alone, according to meta-analysis studies of randomized clinical trials. Outside experimental studies, however, the role radiotherapy can currently play in the management of this type of cancer is difficult to assess because treatment modalities and patient selection criteria differ greatly. We report on the treatment outcome obtained in the Radiotherapy Department of the University of Siena in a series of 86 patients with small-cell lung cancer consecutively referred, January 1986 to January 1992; after a thorough staging, 46 of them were diagnosed as having a "limited disease". A "sequential" chemo-radiotherapy combination was used: irradiation was delivered after the completion of the initial drug treatment. Twenty-four patients (52.5%) achieved a complete and 22 (47.5%) a partial objective remission after chemotherapy, with acceptable early toxicity rates and severity. Twenty-eight of them received irradiation according to the following selection criteria: objective remission after chemotherapy (19 of 24 complete responders, excluding those with initial pleural effusion or worsening medical status during chemotherapy) and initial large tumor bulk (9 of 22 patients in partial remission). The overall treatment outcome rate (median survival: 18 months, 2-year survival: 28%) is in agreement with that of similar previous studies; toxicity rates are also similar (2% of treatment-related deaths). Survival analysis, according to "performance status" score, chemotherapy schedule and the achievement of complete remission with the initial drug management, exhibited significant differences only relative to the latter parameter. Many recent clinical trials suggest that combined chemo-radiotherapy could improve these results: toxicity is however reported as heavy, with this approach. Some guidelines are here considered, which could make this combination reliable also for current clinical use.

Breast-conserving treatment of early breast cancer. Results in a common clinical trial.

Results of large prospective trials, often based on selected series and optimal treatment techniques, indicate that breast conserving therapy is appropriate for most patients with early breast cancer. Questions remain regarding the therapeutic outcome in common practice. We report on a series of 206 consecutive, unselected patients treated with current radiotherapy procedures. The Kaplan-Meier evaluation showed 5- and 8-year survival rates (93%, 91%), distant disease-free survival rates (87%, 85%) and local relapse-free survival rates (90%, 88%) that were comparable to those of the conservative arms in reported randomised trials and to the data from retrospective studies reported by authoritative institutions. However, subanalysis according to prognostic factors such as menopausal status, age and axillary nodal status was of limited value, due to the small number of cases.