Resectability of small-cell lung cancer following induction chemotherapy in patients with limited disease (stage II-IIIb).

A prospective study of multimodality therapy was conducted incorporating adjuvant resection in patients who presented with limited small-cell lung cancer (SCLC). This preliminary report addresses the resectability rate after induction chemotherapy. Twenty-five patients (1 with Stage II, 12 with Stage IIIa, and 12 with Stage IIIb disease) completed the induction regimen of 3 cycles of intravenous cyclophosphamide 750 mg/m2 on day 1, vincristine 2 mg on day 3, cisplatin 20 mg/m2 on days 1-3, and etoposide 100 mg/m2 on days 1-3, (every 3-4 weeks). Patients with complete response or partial response, 10 (40%) and 14 (56%) patients, respectively, were considered for surgical resection. Six were ineligible for surgery because of medical or surgical contraindications, and four refused surgery. Of the 14 patients taken to surgery, 10 had resectable disease (40% of the original group of 25). Three pneumonectomies, two bi-lobectomies, two lobectomies, and two wedge resections were performed. In the remaining patient multiple biopsies revealed no residual disease and resection was not performed. Surgery-related complications included one death, one bronchopleural fistula, and one episode of pneumonia. Induction chemotherapy was generally well tolerated. These preliminary data demonstrate that a significant percentage of patients with SCLC, Stages II-IIIb, can feasibly be resected after response to brief induction chemotherapy.

Radiation therapy following resection of non-small cell bronchogenic carcinoma.

Between 1970 and 1982, 102 patients received postoperative radiotherapy after attempted curative resection of bronchogenic carcinoma at The University of Texas M. D. Anderson Cancer Center. Surviving patients had a minimum follow-up of 3 years. Eight patients had pathological Stage I disease, 29 Stage II, and 65 Stage III. The 5-year actuarial survivals for patients with stages I, II, and III disease were 83%, 55%, and 38%, respectively (p = .04). Corresponding values for patients with N0, N1, and N2 disease were 74%, 56%, and 28% (p = .01). No significant differences in survival were seen based on T stage or tumor histology. Nine patients had gross residual disease following surgery, and 19 had microscopic residual disease. The 5-year actuarial survival was 78% for 12 patients without nodal disease who had known gross (4 patients) or microscopic (8 patients) residual tumor following attempted curative resection. The pathologic status of the hilar and mediastinal lymph nodes was the most significant factor affecting the frequency of metastatic relapse, with 19% of patients with N0, 33% of those with N1, and 69% of those with N2 disease developing distant disease. The low overall rate of recurrence intrathoracically (16%) confirms that postoperative radiotherapy is effective in preventing local relapse even in patients with proven nodal involvement. The impact of adjuvant radiation therapy on survival cannot be determined from these data, and further data are needed, preferably from well designed prospective studies.

Low-dose continuous infusion cisplatin combined with external beam irradiation for advanced colorectal adenocarcinoma and unresectable non-small cell lung carcinoma.

In a dose escalation study, CIS-diamminedichloroplatinum II (cisplatin) was combined with a standard dose of external beam irradiation in 15 patients with localized non-small cell lung cancer (NSCLC) and 16 patients with fixed or recurrent localized adenocarcinoma of the rectum. Cisplatin was given 5 days a week during irradiation using an outpatient portable infusion pump system, at doses of 3.2 mg/m2/24 hr in 15 patients, 4.0 mg/m2/24 hr in 13 patients, and 5.0 mg/m2 24 hr in 3 patients. Twelve of 15 patients with NSCLC received 66 Gy in 33 fractions in 6 1/2 weeks; one received 46 Gy followed by a surgical resection; for the other two patients treatment was discontinued after 50 Gy and 64 Gy, respectively, because they developed distant metastases. The 16 patients with rectal carcinoma received a preoperative dose to the pelvis of 45 Gy in 25 fractions in 5 weeks. Of 12 patients who underwent laparotomy, 10 had a surgical resection, 2 with close or positive surgical margins. Four patients who had resections received an intraoperative electron boost. Of the two patients who did not undergo resection at laparotomy, one received an intraoperative electron boost, the other a boost with interstitial iridium-192. Among the four patients with rectal adenocarcinoma who were not candidates for surgery because of advanced local disease, two had further external beam therapy up to 59.4 Gy, and two had no further therapy. Major toxicity was site-specific, with esophagitis predominating in the patients with NSCLC, diarrhea in the patients with rectal carcinoma, and nausea experienced by both. Cisplatin dose and toxicity seemed to be related. The maximum tolerated dose for low-dose continuous infusion cisplatin given 5 days/week in these patients was 3.2 mg/m2/24 hr combined with 66 Gy in patients with NSCLC and 4.0 mg/m2/24 hr combined with 45 Gy in patients with rectal carcinoma.

Primary malignant tumors of the trachea. A radiologic and clinical study.

Fifty-four cases (55 foci) of primary tracheal malignancies were reviewed retrospectively. Radiologic material was available in 32 cases (33 tracheal foci). The most frequent primary malignant tumor of the trachea was squamous cell carcinoma (54.5%), followed by adenoid cystic carcinoma (18%) and adenocarcinoma (9%). The radiologic appearance of the tumors could be divided into intraluminal, wall-thickening, and exophytic forms. Wall-thickening and exophytic forms in this study accounted for 62% of the tumors. This indicates that malignant tumors of the trachea tend to extraluminal invasion. Tomography and computed tomography are the most helpful methods of radiologic examination for tracheal tumors. Bronchoscopy and radiologic examination are complementary procedures. The chief advantage of imaging is the demonstration of tracheal wall thickening and extraluminal changes. Hemoptysis, dyspnea, and cough were the most common symptoms. Four cases (7%) in our series presented as thyroid tumors due to direct extension into the thyroid gland. Fifteen of the 54 cases (28%) were associated with other carcinomas of the head and neck and the lung.

Predicting the rate and extent of locoregional failure after breast conservation therapy for early breast cancer.

Five hundred thirty-six cases of early breast cancer (T0 to T2, N0 to N1) treated with breast conservation therapy were monitored for a median interval of 64 months. Fifty-five locoregional failures occurred after a median interval of 40 months; the actuarial failure rate was 9% at 5 years and 19% at 10 years. Factors predicting locoregional failure were sought. Young patients had a higher risk of failure than older patients, although their actuarial survival rates were not different. Locoregional failure was defined as advanced if tumor involved skin or was fixed to the chest wall, the diameter was greater than 5 cm, or unresectable nodes were present. There was a significantly higher incidence of advanced recurrence with higher initial tumor stage. Overall, the 5-year survival rate after treatment of locoregional recurrence was 63%. Advanced locoregional failure, however, resulted in a median survival time of 37 months. Further study is required to explain the increased failure rate in younger women. Advanced locoregional failure rarely occurred after treatment of Stage 0 or Stage I tumors, supporting the selection of patients with early disease for breast conservation therapy.

Angiosarcoma arising in an irradiated breast. A case report and review of the literature.

The authors discuss an angiosarcoma that developed in a 50-year-old woman's breast 10 years after she underwent conventional postoperative irradiation with cobalt 60 teletherapy. Although angiosarcoma developing in a lymphedematous arm after radical mastectomy is a well-known phenomenon, and several cases of angiosarcoma are known to have occurred in the chest wall after mastectomy with or without irradiation, only one other case of angiosarcoma in an irradiated breast has been reported. The possible role of therapeutic irradiation in inducing this malignancy is discussed.

Consequences of breast irradiation in patients with pre-existing collagen vascular diseases.

Exaggerated acute and late effects were observed in three of four women with pre-existing collagen vascular disease (CVD) within 2 years after definitive megavoltage radiation therapy for breast carcinoma. Five women with breast carcinoma, who developed CVD 3 months to 10 years after radiation therapy, had no complications. An abnormally severe reaction was observed during treatment of one patient with discoid lupus. The patient developed moist desquamation that persisted for a month, requiring early termination of treatment. One year after treatment, the patient developed paresthesias in the ipsilateral arm. A planned reduction of the prescribed dose in a second patient with progressive systemic sclerosis did not prevent intense erythema at the end of treatment, followed 14 months later by chest wall necrosis, which eventually required multiple surgeries including chest wall resections. The third patient, who had systemic lupus erythematosis, developed necrosis 2 years after treatment, which progressed over 12 years to osteoradionecrosis of the clavicle, sternum and rib cage. Multiple surgeries to repair the defect were complicated by flap necrosis and pleurocutaneous fistulas. The fourth patient died 6 months after radiotherapy without apparent sequelae. None of the patients had evidence of recurrent carcinoma. A history of collagen vascular disease appears to be a contraindication to breast conservation or for elective irradiation for breast cancer.

Testicular seminoma. A study of 103 cases treated at UCLA.

The records of all patients treated at UCLA with stage I through stage III testicular seminoma, diagnosed in 1956-1983, were reviewed. Histologic subtype, therapeutic protocol, survival, and the incidence of subsequent primary malignancies are examined in this presentation. The 10 year cause-specific survival is 93% for stage I and 70% for stage II patients. Of the four patients initially seen with stage III disease, three have achieved long-term disease-free survival after combined irradiation and chemotherapy. Irradiation of the whole pelvis was not associated with improved control for those patients with previous pelvic surgery. Four patients complained of gynecomastia after therapy, and since none of these patients had elevated human chorionic gonadotropin levels, the gynecomastia was attributed to gonadal failure.