Correlation of pre-treatment transurethral resection and prognosis in patients with stage C carcinoma of the prostate treated with definitive radiotherapy--RTOG experience.

Four hundred and ninety-four patients with clinical Stage C carcinoma of the prostate, who were entered onto a phase III RTOG study, have been analyzed as to the potential effect of the pre-treatment transurethral resection (TUR) of the tumor. Treatment consisted of definitive irradiation to the prostate (6500-7000 cGy) and regional lymphatics (4500-5000 cGy). A total of 202 patients underwent pre-treatment TUR. This population was compared with the remaining 292 patients as to the rate of locoregional failure, incidence of distant metastases, disease-free survival, and survival. The TUR population fared significantly worse for all four end-points. To account for uneven distribution of recognized prognostic factors the results were then adjusted using stratified Mantel-Haenszel tests. The stratification process resulted in a reduced level of significance in the differences between the two populations. However, a trend toward a higher incidence of distant metastases could be observed within most strata. The trend was most pronounced in subpopulations characterized by Gleason score 6-7 and normal serum acid phosphatase (SAP). For the population characterized by Gleason score 6-10 and normal SAP, the differences in the incidence of distant metastases retained statistical significance. Whether these findings are secondary to tumor dissemination during TUR or are due to incompletely identified selection biases remains to be demonstrated in future (prospective) studies.

Correlation of radiotherapeutic parameters and treatment related morbidity in carcinoma of the prostate--analysis of RTOG study 75-06.

Treatment related morbidity, recorded in patients entered onto a RTOG phase III study (testing the value of periaortic irradiation in locally advanced carcinoma of the prostate), has been correlated with radiotherapeutic parameters to identify and quantify the relationship with treatment volumes, doses, and techniques. Between 1976 and 1983 a total of 526 analyzable cases were entered onto the study. The study design entailed randomization to either pelvic irradiation followed by a prostate boost or pelvic and periaortic irradiation followed by a prostate boost. Periaortic irradiation was not associated with a significantly increased incidence of bowel injuries manifested by diarrhea. No correlation between the total dose to the regional lymphatics (ranging from 4400 to 5100 cGy) and the incidence of bowel and bladder injuries could be established. Doses to the prostate in excess of 7000 cGy have not resulted in a significantly increased incidence of bladder injuries, but have been associated with a significant increase in the incidence of bowel injuries manifested by diarrhea. The techniques of pelvic irradiation did not seem to significantly influence the incidence of bowel or bladder complications. The technique of delivery of the prostatic boost did seem to influence the incidence of bowel injuries. This refers to the lateral boost technique and the perineal boost technique which have been associated with a higher incidence of diarrhea. All of the conclusions based on this analysis are applicable only to treatment volumes and dose ranges used in this study and to conventional fractionation of 180 to 200 cGy per day.

Prognostic factors in carcinoma of the prostate--analysis of RTOG study 75-06.

A total of 566 evaluable patients were accessioned to a phase III RTOG study of extended field irradiation in carcinoma of the prostate from 1976 to 1983. Eligible patients were those with locally advanced disease, either clinical Stage C or clinical Stage A2 or B with pelvic lymph node involvement. The treatment consisted of irradiation of the regional lymphatics followed by a boost to the prostate. The data have been analyzed extensively to identify variables of potential prognostic significance. The assessed factors include tumor size, clinical stage, the degree of histological differentiation, nodal status, serum acid phosphatase status, hormonal management status, age, and race. These factors have been assessed as to their interdependence and correlation with the clinical course (study endpoints) using univariate analyses and Cox's Regression model. Significant interdependence of tumor size and Gleason score and tumor size and acid phosphatase was identified. The population receiving hormonal management either prior to or during radiotherapy had a significantly higher proportion of high grade tumors. Correlation of the assessed variables and the study endpoints (local control, incidence of distant metastases, NED survival, survival) singled out the degree of histological differentiation as the most powerful prognostic factor for all the endpoints. Age proved a useful predictor of local control (younger patients failed at a significantly higher rate), as did tumor size. Elevation of serum acid phosphatase correlated well with the incidence of metastatic disease but was not a useful predictor of survival. Tumor size and hormonal management status correlated well with the incidence of metastatic disease but only when analyzed separately from other factors. Their prognostic value was absent when Cox regression analysis was applied. Nodal status did not correlate well with any of the study endpoints, indicating then that in patients with clinical Stage C disease, treated with definitive radiotherapy to the prostate and regional lymphatics, this parameter may have limited prognostic usefulness. Although patients who received concomitant hormonal management had a significantly higher proportion of high grade lesions, their clinical course fared favorably in comparison with the population not receiving concomitant hormonal management. This may indicate a beneficial effect of adjuvant hormonal treatment which needs to be tested in a prospective study.

Prognostic significance of nodal involvement in locally advanced (stage C) carcinoma of prostate--RTOG experience.

A total of 500 patients with extracapsular extension (clinical Stage C) carcinoma of the prostate received definitive radiotherapy directed to the prostate and the regional lymphatics. Pretreatment evaluation of the regional lymphatics was optional and was done in 245 patients who underwent either staging laparotomy or lymphangiography. The remaining 255 patients had no nodal evaluation. In 72 of the node-evaluated patients there was evidence of spread to the pelvic lymphatics and in 173 patients lymph nodes were negative. The three populations (lymph nodes-not evaluated, lymph nodes-involved, and lymph nodes-not involved) were analyzed as to the distribution of the recognized prognostic variables and compared as to the study end points (locoregional failure, incidence of distant metastases, disease-free survival, and survival).

[Stereotactic surgery for intracranial mass lesions: diagnosis and treatment]. / Cirurgia estereotáctica para processos expansivos intracranianos: diagnóstico e tratamento.

The authors present a study about 50 stereotactic procedures for intracranial lesions. In 12 cases stereotaxis was used as a treatment: stereotactic surgical resection (5 patients) and aspiration of lesions (7 patients). This study confirms the great accuracy and low morbidity of the stereotactic techniques. Computed tomography and magnetic resonance imaging determinate the precise stereotactic coordinates, but in some cases it is necessary to perform stereo-angiography. The stereotactic surgical resection of brain tumors allows the treatment of deep lesions or located at functional areas and considered to be inoperable before. The related literature is discussed.

[Microsurgical treatment of trigeminal neuralgia. A study of 50 cases]. / Traitement microchirurgical de la névralgie du trijumeau. Etude sur 50 cas.

The authors present a study of 50 patients with trigeminal neuralgia treated by posterior fossa microsurgery. Microvascular decompression of the trigeminal nerve was performed in 48 patients. In 2 cases no neuro-vascular compression was found, and a partial rhizotomy was carried out. In 98% of the cases there was postoperative abolition of the pain. Two cases of wound infection and three CSF fistulas were the operative complications. These patients were reoperated and cured. Twenty five patients were reviewed between 13 months and 8 years after surgery. Twenty one remained painfree without any drug, 3 were painfree taking 200 to 400 mg Carbamazepineper day, and 1 patient was reoperated after two years without pain because of recurrence of the neuralgia. There was no mortality or major morbidity in this series. Our results and the literature concerning this method are discussed in this article. In conclusion, microvascular decompression may be indicated in a large number of patients with essential trigeminal neuralgia due to its excellent pain control, no mortality and low morbidity.

Improved survival in the treatment of advanced Hodgkin's disease at a nonuniversity institution (1970-1979).

From 1970 through 1979, 89 patients with Hodgkin's disease were treated at the Marshfield Clinic/St. Joseph's Hospital. After the pathologic material was reviewed, the patients were analyzed to compare Group I (1970-1973) with Group II (1974-1979). Demographic characteristics in the two groups were similar. In the decade, 76% of patients achieved complete remission. In advanced-stage disease, 50% of patients achieved complete remission in Group I compared with 68% in Group II. At 5 years, 50% of patients were alive without COPP (cyclophosphamide, vincristine, procarbazine, prednisone) chemotherapy; with this treatment, 75% of patients survived (P = 0.02). There was improved survival comparing Group I (56% at 5 years) with Group II (76% at 5 years) patients with advanced disease (P = 0.004). More aggressive combination chemotherapy (COPP) was related to the improvement in survival (P less than 0.001). The advances in treatment made by cooperative groups and universities are being transferred to nonuniversity institutions, with appropriate improvement in survival of Hodgkin's disease.