Treatment of locally unresectable cancer of the stomach and pancreas: a randomized comparison of 5-fluorouracil alone with radiation plus concurrent and maintenance 5-fluorouracil--an Eastern Cooperative Oncology Group study.

One hundred ninety-one patients with pathologically confirmed, locally unresectable adenocarcinoma of the stomach (57 patients) and pancreas (91 patients), were randomly allocated to therapy with 5-fluorouracil (5-FU) alone, 600 mg/m2 intravenously (IV) once weekly, or radiation therapy, 4,000 rad, plus adjuvant 5-FU, 600 mg/m2 IV, the first three days of radiotherapy, then follow-up maintenance 5-FU, 600 mg/m2, weekly. Forty-three patients (22%) could not be analyzed because of ineligibility or cancellation, thus 148 patients were evaluable. The median survival time was similar for both treatment programs and for both types of primary carcinoma, and was as follows: gastric primary carcinoma, 5-FU, 9.3 months; 5-FU plus radiotherapy, 8.2 months; pancreatic primary carcinoma, 5-FU, 8.2 months; 5-FU plus radiotherapy, 8.3 months. Substantially more toxicity was experienced by patients treated with the combined modality arm than by those patients receiving 5-FU alone. Severe or worse toxicity experienced by patients with gastric primary carcinoma treated by 5-FU was 19%, and the combined modality arm was 31%. The toxicity experienced by patients with pancreatic primary carcinoma treated with 5-FU was 27%, and the combined modality arm was 51%. Significant prognostic variables included: weight loss in stomach-cancer patients; and performance status, degree of anaplasia, and reduced appetite in pancreas-cancer patients.

Combination chemo-radiotherapy for residual, recurrent or inoperable carcinoma of the rectum: E.C.O.G. study (EST 3276).

Thirty evaluated patients were randomized to either continuous radiation + 5-FU (16 patients), or split-course radiation + 5-FU (14 patients) for the treatment of residual, recurrent, or inoperable carcinoma of the rectum or recto-sigmoid. Twenty-one of these patients received maintenance MeCCNU + 5-FU chemotherapy following radiation. Entry was terminated when late treatment reactions were seen in the precursor pilot study. Twenty-four of the patients have died; the estimated median survival is 17 months in each of the treatment arms. Performance status was the only significant prognostic factor for survival. The rate of severe, acute reactions during the radiation treatment period was higher for the continuous-course than for the split-course regimen (69 vs. 21%, p = .01). The rates of severe late treatment reactions, 23% (7 of 30), and severe chemotherapy toxicity, 48%, were similar for the two treatment programs. Late treatment reactions, primarily bowel complications, were seen from 3 to 23 months after radiation in 3 patients treated with continuous course, and 4 patients treated with split course. Ten of 21 patients (48%) who received maintenance chemotherapy had severe or worse toxicity. Toxicity was seen for 6 of 12 continuous-course, and 4 of 9 split-course patients. Twenty-seven patients have had disease progression, and the median length of disease control is 11 months.

Impact of local radiation in the management of salivary gland carcinomas.

Seventy patients with salivary gland carcinoma (63% major gland and 37% minor gland) are reviewed. Histologies included adenoid cystic (54%), mucoepidermoid (16%), and adenocarcinoma (14%). Patients were analyzed according to extent of surgery and whether or not adjuvant postoperative radiotherapy was given. There is no difference in survival in patients who had complete excision of gross tumor with or without adjuvant radiotherapy. Patients who did not undergo radiotherapy had a 62% actuarial risk of locoregional failure at 5 years, with a 20% risk in the adjuvantly irradiated group (P less than 0.001). A failure analysis demonstrates that among the 44% of patients with recurrence 71% (22/31) failed locoregionally and 69% (21/31) had distant metastases. Twenty-seven percent (19/70) died of disease, with 31% (6/19) dying of locoregional disease and 26% (5/19) of distant disease. Implications for management are discussed.

Successful estrogen therapy for post-adrenalectomy relapses of breast cancer.

Four postmenopausal women are described in whom breast cancer responded both to bilateral adrenalectomy and bilateral oophorectomy, and subsequently, after relapse, to estrogen therapy. This paradoxical finding demonstrates the complexity of the response of breast carcinoma to hormone manipulations. Simple estrogen dependence and estrogen suppression of pituitary mammotrophins are seen to be inadequate explanations of this phenomenon. Seven fundamental observations are listed that have to be accounted for by hypotheses concerning the endocrinology of breast cancer. It is suggested that in the past we have perhaps overlooked (1) the difficulty of extrapolating observations on experimental animal tumours to spontaneous human neoplasms, (2) the fact that there may be more than one type of breast cancer, and (3) the important role that must be played by the different tissues bearing the metastases.

Radiation therapy in lymphomatoid granulomatosis.

A 59-year-old woman with lymphomatoid granulomatosis (LYG) involving the lungs and skin is reported. This patient had many large, ulcerated cutaneous lesions that progressed during prednisone and cyclophosphamide therapy. However, the cutaneous disease responded to radiation treatment in terms of relief of symptoms and objective evidence of subsidence of local disease. The patient died of an unrelated cause 2 years after the establishment of the diagnosis of LYG. At autopsy, the skin lesions were completely healed, with no residual disease. However, there was evidence of the progression of LYG into a malignant large cell lymphoma involving the liver and lung. A discussion of the nature of LYG and the role of radiotherapy in localized disease is presented.

Management of primary bladder cancer by a multidisciplinary team.

Results of management of a closed series of primary bladder carcinoma over a 20-year period by a multidisciplinary team are presented. Patients were classified by the TNM method before treatment. These experiences indicate that stage and grade are relevant to prognosis and treatment. The TNM classification can be precise and practical when used diligently by a treatment team. Although no new methods of treatment are offered, the treatment now available may be utilized to better effect if programmed to allow care of the patients by a team, especially if the team explores the limits of radiation and surgery in their hands.