Clinical experience with interstitial thermoradiotherapy for localized implantable pelvic tumors

Twenty-six patients (20 females, 6 males) with localized tumors of the pelvis, including 3 primary advanced (PRIM), 7 persistent (PERS), 10 recurrent (REC), and 6 metastatic (MET) tumors, were treated with a combination of low-dose rate (LDR) iridium 192 interstitial radiotherapy (IRT), interstitial 915 MHz microwave hyperthermia (IHT), and external beam radiotherapy (RT). Histological diagnoses were squamous cell carcinoma in 13 (50%), adenocarcinoma in 12 (46%) and soft tissue sarcoma in 1 (4%) lesion. Tumor sites were cervix in 8 (31%), colorectum in 6 (23%), vagina in 4 (15%), anus in 3 (12%), ovary in 2 (8%), and other sites in 3 (12%) lesions. IHT was administered immediately before iridium 192 was placed and after its removal for 45-60 minutes at 41-44 degrees C. On December 31, 1991 median follow-up was 25 months (mean: 23 months; range: 5-65 months). At 3 months follow-up (FU), complete remission (CR) occurred in 17 (65%), partial remission (PR) in 7 (27%), and no change or progressive disease (NC/PD), in 2 (8%) lesions. At 12 months FU, in 16 of 21 patients (76%) local control (LC) was achieved, with 1 (5%) patient exhibiting a slow tumor regression. After combined IRT-IHT locoregional relapse or tumor regrowth occurred in 8/26 (31%): 5 (19%) outside and 3 (12%), inside the previously treated volume; relapses occurred within 8-30 (mean: 18) months of follow-up. Factors influencing initial (3 months FU) and long-term tumor response (12 months FU) included tumor class, tumor volume, total radiation dose, and thermal parameters with "good quality of heating" (TQ 41 degrees C > or = 75%) and high minimum tumor temperature (Tmin(av) > or = 41 degrees C). Treatment toxicity was acceptable: whereas 8 (31%) patients experienced acute side effects, which subsided within weeks, 7 (27%) developed long-term complications. Thermal damage was associated with IHT treatments exceeding maximum average temperatures of > or = 44 degrees C and maximum peak temperatures of > or = 45 degrees C.

Expressions of N-myc and ras oncogene products in neuroblastoma and their correlations with prognosis

Thirty-six neuroblastomas were studied to determine the clinical significance of the N-myc gene product, N-myc, and the ras gene product, p21. The expressions of both gene products were analyzed immunohistochemically using formalin-fixed paraffin sections. Neuroblastoma cells were positive for N-myc expression in 13 cases and for p21 expression in 19 cases. N-myc expressions showed no significant relation to any clinical prognostic factor, whereas p21 expression was well correlated with clinical staging and Shimada's classification. There was a tendency for p21 expression to be low in N-myc(+) tumors, whereas p21 expression was frequently detected when N-myc expression was absent. The survival rate for N-myc(-) patients was significantly higher than for N-myc(+) patients (P < 0.01). The survival rate for p21(+) patients was significantly higher than for p21(-) patients (P < 0.001). In addition, N-myc(+) and p21(-) patients showed a strong tendency towards a poor prognosis, whereas a combination of p21(+) and N-myc(-) indicated a good prognosis (P < 0.01). The results suggest that expressions of N-myc and p21 detected by immunohistochemical staining could be among the most reliable prognostic indicators in neuroblastoma patients.

Re-evaluation of indications for percutaneous nephrostomy and interventional uroradiological procedures in pelvic malignancy

Twenty-two patients with advanced cancer involving the pelvis were treated by percutaneous uroradiological techniques. Percutaneous nephrostomy was performed for renal failure or urosepsis or before chemotherapy. In 8 patients, ureteric stents were also placed by the antegrade route, across malignant ureteric strictures, following nephrostomy. In another 8 patients, the ureteric obstruction could not be crossed and permanent nephrostomies were required. Fifteen patients were able to achieve a useful life but in the other 7 patients there was no improvement in their quality of life and they all died 1 month after intervention. Percutaneous nephrostomy also contributed to the death of 1 patient. Not all obstructed kidneys require drainage and in patients with disseminated or advanced disease involving the pelvis, the indications for intervention need to be individually assessed. An improvement in laboratory criteria of renal function following intervention does not necessarily result in improvement in quality of life. This retrospective study highlights the difficulty in selection of patients with advanced disease for intervention and previously suggested guidelines for intervention are reviewed.

[Combined surgical and radiotherapeutic treatment of pelvic wall recurrences: report of experiences after 3 years]

CORT has been developed to treat recurrent gynaecological malignancies infiltrating the pelvic wall unilaterally. The surgical part consists of: (i) staging laparotomy/lymphadenectomy, (ii) maximum tumour resection at the pelvic wall and exenteration of infiltrated central pelvic organs, (iii) implantation of guiding tubes on the residual tumour/tumour bed on the pelvic wall, (iv) pelvic wall plasty with muscle, musculocutaneous and omentum flaps, (v) operative reconstruction of bowel, bladder and perineo-vulvo-vaginal functions. Radiation is performed as interstitial high dose rate brachytherapy through the implanted tubes. Patients without prior pelvic irradiation receive in addition, whole pelvis teletherapy. CORT has been evaluated in a prospective phase I and II trial at the University of Mainz. Within a 3-year period, 21 patients with pelvic wall recurrences from various gynaecological primary tumours were treated. Seventeen patients had been irradiated as (part of) the previous therapy with a median total mid-pelvic dose of 65 Gy (range 40-100 Gy). There was no operative mortality. Five patients developed complications necessitating surgical intervention. One patient died from fatal thromboembolism 6 months after CORT without evidence of tumour progression. In 14 patients, local tumour control has been achieved. After a median follow-up period of 27 months (range 6-38 months) Kaplan-Meier life table analysis revealed an actuarial survival probability of 55% (recurrence-free 49%). We conclude from these preliminary results, that the CORT procedure for the treatment of pelvic wall recurrences is feasible and may lead to encouraging therapeutic success in selected patients, whose situation had been hopeless so far.

Effect of rest interval on tumor and normal tissue response--a report of phase III study of accelerated split course palliative radiation for advanced pelvic malignancies (RTOG-8502)

From August 1985 through September 1989, 284 patients with advanced pelvic malignancies were entered into a trial (RTOG 8502) of palliative split course radiation (4440 cGy in three courses of 1480 cGy/2 days/4 fractions with a rest of 2-4 weeks between courses). The initial 148 patients were part of a Phase II acceptable response rate and minimal acute or late toxicity (IJRBP 17:659-662, 1989). The present analysis is a report of the subsequent 136 patients randomized between rest intervals of 2 weeks versus 4 weeks to determine if length of rest would influence tumor response or patient toxicity. The patients were stratified for performance status (Karnofsky Performance Status) and histology. The patients were evenly matched for age and sex. There was a trend toward increased acute toxicity incidence in patients with shorter rest interval (5/68 versus 0/68; p = .07). Late toxicity was not significantly different between the two groups. Decreasing the interval between courses did not result in a significant improvement in tumor response (CR+PR = 34% vs. 26%, p = n.s.). More patients in the 2 week groups completed all three courses (72% vs. 63%). Not surprisingly, patients completing cell three courses had a significantly higher overall response rate than for patients completing less than three courses (42% vs. 5%) and higher complete response rate (17% vs. 1%). A multivariate analysis indicated performance status as the significant predictor for number of courses completed. For Karnofsky Performance Status greater than or equal to 80, the survival at 12 months was 40% for the 2 week interval and 25% for the 4 week interval. Performance status and histology were the only significant variables in a multivariate analysis of survival.

Recurrent squamous cell carcinoma of the vulva: a study of 73 cases

In a study of 73 patients, diagnosed with recurrent squamous cell carcinoma of the vulva between 1975 and 1990, the effect of clinical variables on the outcome was evaluated. The overall 5-year survival rate was 35.2%. Of the 73 patients, 33 (45.2%) originally had Stage I or II disease and 40 (54.8%) Stage III or IVA; 49 (67.1%) recurred less than 2 years and 24 (32.9%) more than 2 years after initial surgery; and 39 (53.4%) recurred on the vulva only, while 34 (46.6%) recurred beyond the vulva. Of 59 patients who had groin lymph node dissection at initial surgery, 26 (44%) had negative and 33 (56%) had positive nodes. By means of univariate analyses, a significant worsening in outcome was demonstrated with advancing original stage of disease (P < 0.001), positivity of groin lymph nodes (P < 0.01), shortening of recurrence-free interval (P < 0.001), and extension of recurrence beyond the vulva (P < 0.001). In a multivariate analysis (Cox proportional hazards model) recurrence site was the strongest and the only significant predictor of survival. The death risk showed a 3.7-fold increase (95% confidence intervals: 1.6 to 8.7, P = 0.002) for recurrence beyond the vulva over recurrence on the vulva only. For patients who recurred in the vulva only, wide radical local excision provided acceptable survival results, while for all other patients, regardless of type of treatment, the outcome was poor.

Neuroblastoma--a surgical perspective

The role of an aggressive surgical policy in the management of neuroblastoma (NBL) was examined in a retrospective study from a total of 57 patients presenting to a single institution between 1979 and 1989. Surgery consisted of either primary excision of tumour or elective resection following intensive chemotherapy. Two year disease-free survival (DFS) for the entire group was 100% for Stage I patients (n = 2), 86% for Stage II (n = 7), 55% for Stage III (n = 11), 12% for stage IV (n = 33) and 50% for stage IVs (n = 4). In all long-term survivors, surgical excision of primary tumour had been achieved. Elective surgery of primary tumour was not performed in six patients with Stage IV disease; median survival for these patients was eight months compared with 19 months for those other patients with Stage IV disease who did have surgery +/- high dose melphalan and autologous bone marrow rescue. Postoperative complications were documented in 13 of 48 operated patients (27%), emphasising the technical challenges encountered in resection of NBL. Age at presentation and site of primary tumour were major factors affecting prognosis: patients who presented < 1 years of age (n = 15) achieved 80% DFS, > 1 year and < 2 years (n = 12), 33%, and > 2 years (n = 30) 13%; 10 of 11 patients (91%) with primary supradiaphragmatic disease are alive and well compared with 10 out of 46 (22%) with infradiaphragmatic disease (P = 0.01). Based on the experience from this centre, it would appear that surgery can be curative for patients with Stage I, II and III disease but can only, at best, prolong DFS for Stage IV patients. Alternative therapeutic strategies are indicated for this latter group of patients.

Localized dumbbell neuroblastoma: a study of 25 cases treated between 1982 and 1987 using the same protocol

Among the 108 non-metastatic neuroblastomas treated at the Institut Gustave Roussy between 1982 and 1987, 25 dumbbell neuroblastomas were observed. Therapeutics included: 1) an initial laminectomy in forms with neurological deficit; 2) surgical excision of the primary tumor; 3) preoperative chemotherapy in children in which the primary tumor was considered as unresectable at diagnosis and postoperative chemotherapy in cases of incomplete resection; and 4) radiation therapy on macroscopic residual disease. Fifteen out of 25 (60%) presented a neurological deficit. A laminectomy was performed in 14 cases. Neurological recovery was good in 4 cases, partial in 4 cases, and absent in 4 cases. Two patients were worse after the procedure. The event-free survival was 88%. This high survival rate is linked: 1) to the non-metastatic stage; 2) to a high proportion of children under 1 year of age (18/25) (median age = 7 months); and 3) to a high proportion of thoracic location (12/25). The high incidence of macroscopically incomplete excision (13/25) did not jeopardize the prognosis. Out of the 22 survivors, there were 8 cases of major neurological sequellae (36%) and 5 cases of major orthopedic ones (26%). The coexistence of a serious functional prognosis and an excellent vital prognosis for these patients has led us to analyse the therapeutic modalities, to reevaluate the necessity of routine initial neurosurgical removal by laminectomy and to discuss the use of first line chemotherapy.

Surgical resection following interleukin 2 therapy for metastatic renal cell carcinoma prolongs remission

Records of 399 patients with metastatic renal cell carcinoma treated with interleukin 2 with or without lymphokine-activated killer cell immunotherapy enrolled in 14 separate clinical trials from multiple institutions were reviewed to determine whether patients with a partial response to interleukin 2 therapy would benefit from surgical resection of residual tumor. Sixty-two patients demonstrated objective responses (15.5%), 18 (4.5%) complete and 44 (11.0%) partial. Eleven patients underwent resection of residual tumor in the lung, kidney, retroperitoneum, or pelvis so that they had "surgically no evidence of disease" (SNED). Of these, 10 had partial responses, and one patient with progressive disease had a complete response. Comparison of response duration showed no difference between the complete response and SNED groups, but there was a significant difference between each of these groups and the partial response group. At this writing, all 11 patients in the SNED group remained alive without evidence of disease (median follow-up, 21 months). In contrast, only 14 patients (76%) with complete responses and 15 patients (35%) with partial responses remained free of disease progression. Enhanced survival of the complete response and SNED groups compared with the partial response group borders on significance and awaits longer follow-up. These data suggest that surgical resection, if technically feasible, may benefit patients who show a partial response to interleukin 2 treatment for metastatic renal cell carcinoma.

[Intraoperative radiotherapy for local recurrence of intrapelvic malignancies]

From 1986 to 1992, seventeen patients with recurrent intrapelvic malignancies have been treated with intraoperative radiotherapy (IOR) in Saitama Cancer Center. They were 8 males and 9 females. The age ranged 44 to 83 (mean:61.6). The primary organs involved were rectum in 7, urinary bladder in 5, uterine cervix in 3 and ovary in 2. Invasion of recurrent disease into bony pelvis was noted in all but one patient. A total of 27 IORs were done on 18 occasions for 17 patients. The mean radiation dose was 25.6 Gy (range: 12-30). The cones used were 4 to 7 (mean: 5.4) cm in diameter. Debulking surgery was performed in 13 patients just before IOR. Chemotherapy and/or external radiotherapy were done in addition to IOR in most of the cases. As of May 1992, 14 patients had died with a mean survival time of 10 months (range:0.5-29.8). IOR seems to be useful in controlling the intrapelvic recurrent disease and may warrant further investigation.

The combined operative and radiotherapeutic treatment (CORT) of recurrent tumors infiltrating the pelvic wall: first experience with 18 patients

CORT is a new radiosurgical treatment concept for patients with recurrent gynecologic malignancies infiltrating the pelvic wall. The operative part consists of (i) staging laparotomy; (ii) maximum debulking of the tumor from the pelvic wall and exenteration of infiltrated central pelvic organs; (iii) implantation of brachytherapy guiding tubes on the residual tumor/tumor bed at the pelvic wall; (iv) pelvic wall plasty with muscle and omentum flaps to create a protective distance between the tubes and the pelvic hollow organs and to induce therapeutic angiogenesis; and (v) surgical reconstruction of bowel, bladder, and vulvoperineovaginal functions. Radiation is given postoperatively as fractionated HDR brachytherapy via the implanted tubes. Patients without prior pelvic radiation also receive preoperative whole pelvis teletherapy. Eighteen patients with recurrent malignancies infiltrating one pelvic wall have been treated with CORT in a prospective phase I/II trial at the University of Mainz. Fourteen patients had a history of radiation therapy with midpelvic doses of 40-100 Gy (median, 65 Gy) as primary treatment. Eleven patients (61%) are without evidence of disease at 6-32 months (median, 15 months) follow-up. Four patients have died from pelvic progression and distant metastases, and two patients are alive with disease after 12 months. There was no operative mortality; however, one patient succumbed from fatal thromboembolism 6 months after therapy. Three patients with prior radiation of greater than 75 Gy had to be treated for intestinal fistulas. We conclude that CORT is feasible with encouraging preliminary results.

Composite resection of posterior pelvic malignancy

Advanced pelvic cancer is a formidable challenge to surgical resection. These tumors commonly invade the bony pelvis, may involve other viscera, and usually have been irradiated previously. The authors are presenting experience with 76 patients who had composite resection of posterior or lateral pelvic malignancy. Fifty-eight patients had secondary cancers involving the musculoskeletal pelvis. This included 47 patients with advanced carcinoma of the rectum (41 curative, 6 palliative), 10 epidermoid cancers of the anorectum (8) or cervix (2), and 1 bladder cancer. Among the 18 patients with primary pelvic tumors were three patients with chordomas, six with bone tumors (osteosarcoma chondrosarcoma, grade III giant cell tumor), and nine with soft tissue tumors. All required major resection of the sacrum or pelvic side walls, and one half had an additional exenterative procedure. The overall mortality rate was 7.9%. Long-term estimated survival was 24% in patients having curative resection of recurrent rectal cancer, and 22.5% in 10 patients with advanced epidermoid cancer. Fifty per cent of patients with primary bone or soft tissue tumors survived from 13 to 88 months. Most patients had reasonable return of function, and were able to return to work or resume their normal previous lifestyle.

Sacral resection for control of pelvic tumors

A surgical approach for treating patients with resected, recurrent, posterior pelvic visceral tumors involving the sacrum is detailed. Of 11 patients, 9 had rectal cancers, 1 had chordoma, and 1 had cancer of the cervix. Five total pelvic exenterations and five posterior exenterations were performed en bloc with involved sacrum. One patient had a sacral resection only. Surgical mortality was 9%, and the average hospital stay was 1 month. Mean disease-free survival was 1 year, and mean survival was 3 years. Absolute cure rate was 18% with a complete 5-year follow-up. This experience confirms the value of this procedure in selected patients.

Urinary dopamine/noradrenaline and dopamine/vanillylmandelic acid ratios as a reflection of different biology of adrenergic clones in children's neuroblastic tumors

The results of calculations of urinary dopamine/noradrenaline (DA/NAd) and dopamine/vanillylmandelic acid (DA/VMA) ratios in 54 untreated children with neuroblastic tumors are reported. Thirteen patients were in the prognostically favorable group (stages I, II, and IV-S and ganglioneuroma [GN]), and 41 had advanced neuroblastoma (stage III and IV). Among patients with ganglioneuroma and favorable neuroblastoma (n = 13), of whom all were survivors, the urinary DA/NAd and DA/VMA ratios exceeded 1.8 in only 2 cases of stage IV-S and stage I, respectively. In the advanced neuroblastoma group, the DA/NAd and DA/VMA ratios exhibited a wide range of values, but among the stage III and IV survivors (n = 10), DA/NAd ratios greater than 1.8 were noted in only 3 patients. The DA/VMA ratio was not greater than 1.8 in those 3 patients. The mean DA/NAd and DA/VMA proportions in the population comprising all survivors were 1.8 +/- 2.7 (mean +/- SD) and 1.1 +/- 0.4, respectively. The same computations carried out in patients who died showed higher values, ie, the mean DA/NAd and DA/VMA ratios were 5.2 +/- 6.3 and 5.6 +/- 10.5, respectively, showing the difference in DA/NAd and DA/VMA ratios between prognostically favorable and unfavorable groups. Of 23 survivors, only 4 had DA/NAd ratios greater than 1.8 (17%), while 24 of 31 children who died (77%) had DA/NAd ratios was greater than 1.8. The reported results suggest dissimilarity in the catecholamine metabolism of adrenergic clones with respect to the stage of advancement of neoplastic disease.

High energy neutron treatment for pelvic cancers: study stopped because of increased mortality

OBJECTIVE

To compare high energy fast neutron treatment with conventional megavoltage x ray treatment in the management of locally advanced pelvic carcinomas (of the cervix, bladder, prostate, and rectum).

DESIGN

Randomised study from February 1986; randomisation to neutron treatment or photon treatment was unstratified and in the ratio of 3 to 1 until January 1988, when randomisation was in the ratio 1 to 1 and stratified by site of tumour.

SETTING

Mersey regional radiotherapy centre at Clatterbridge Hospital, Wirral.

PATIENTS

151 patients with locally advanced, non-metastatic pelvic cancer (27 cervical, 69 of the bladder, seven prostatic, and 48 of the rectum).

INTERVENTION

Randomisation to neutron treatment was stopped in February 1990.

MAIN OUTCOME MEASURES

Patient survival and causes of death in relation to the development of metastatic disease and treatment related morbidity.

RESULTS

In the first phase of the trial 42 patients were randomised to neutron treatment and 14 to photon treatment, and in the second phase 48 to neutron treatment and 47 to photon treatment. The relative risk of mortality for photons compared with neutrons was 0.66 (95% confidence interval 0.40 to 1.10) after adjustment for site of tumour and other important prognostic factors. Short term and long term complications were similar in both groups.

CONCLUSIONS

The trial was stopped because of the increased mortality in patients with cancer of the cervix, bladder, or rectum treated with neutrons.

Chondrosarcoma of the pelvis: the role of palliative debulking surgery

Curative resection of pelvic chondrosarcoma is sometimes technically impossible. In such cases, surgical debulking on one or more occasions may provide symptomatic relief. In a series of 12 patients with pelvic chondrosarcoma, three have undergone a single debulking procedure and three two or more such procedures. All six patients obtained symptomatic relief and five remain alive and well at a median of 12 months from surgery. Two patients have no clinical evidence of recurrent disease 21 and 25 months after the last debulking procedure.

[Pelvic recurrences after curative surgery for rectal cancer]

This report updates an experience with local recurrences of rectal cancer after curative surgery. Overall 13 year period (1976-1988) 254 patients were operated on in the II Surgical Clinic of Parma University for rectal cancer. Only 122 patients who underwent potentially curative resection were examined. Approximate recurrence rates according to patients age, site, type and stage of primitive tumour, tumour complications and surgical procedures were evaluated. The overall local failure rate was 17.2% with 12 patients having local failure alone and 9 patients having concurrent local failure and distant metastasis. Local failure occurred predominantly in tumour bed, involving the anastomosis in 2 cases. Relapse developed primarily at colo-rectal anastomosis in only 1 patients, 20% of recurrences were diagnosed within the first postoperative year; 65% within the second and 90% within the third. Stage of primary tumour was the most predictive factor for eventual relapse. Minute foci of tumour not encompassed by the first operation led to local recurrences in most of the cases, but relapses were independent of operative procedures adopted. The authors conclude that surgery, even if correctly performed, is not sufficient to prevent the risk of local recurrence of rectal cancer. They believe that routine adjuvant radiation therapy after surgical treatment of rectal cancer should improve survival rate.

Myeloablative combination chemotherapy without total body irradiation for neuroblastoma

Myeloablative treatment intensification in 25 patients diagnosed when older than 12 months of age with stage IV neuroblastoma included sequential delivery of cisplatin 120 mg/m2 x 1, hyperfractionated radiation (2,100 cGy) to the primary site and adjacent lymph nodes, carmustine (BCNU) 200 mg/m2 x 1, melphalan 60 mg/m2/d x 3 (n = 13) or thiotepa 300 mg/m2/d x 3. (n = 12), and etoposide (VP 16) 300 mg/m2/d x 3. Seventy-two hours after the last dose of VP 16, histologically tumor-free and 4-hydroperoxycyclophosphamide (4-HC; 100 mumol/L)-purged autologous bone marrow (ABMT) was infused. Acute toxicities included grade 3 to 4 oral mucositis, grade 1 to 2 diarrhea, and fevers. No patient required infusion of unpurged reserve autografts. At ABMT, 16 patients (group I) were progression-free 6.5 months to 14 months (median, 9 months) from diagnosis: seven remain progression-free 20 months to 46 months (median, 39 months) off therapy, six relapsed 4 months to 17 months post-ABMT, and three died of toxicity (candidiasis, metabolic derangement, and venoocclusive disease [VOD]). The event-free survival of group I patients is 44% at 24 months post-ABMT. Nine patients (group II) were in second remission at ABMT, including three who had relapsed after other transplant procedures: two are progression-free 24 months and 41 months off therapy, four relapsed 3 months to 12 months post-ABMT, and three died of toxicity (aspergillosis, hemorrhagic cystitis, VOD). Only one of 10 relapses involved a primary site, suggesting a beneficial effect of local radiation. In terms of survival or toxicity, an advantage for melphalan or thiotepa was not evident. Regimens such as this may prolong the survival of selected patients with poor-risk neuroblastoma, but concerns over late relapses and toxicity mandate continuing efforts to devise alternative, less risky, and more clearly beneficial approaches for definitive ablation of neuroblastoma.

[Combined interventions in non-organic neoplasms of the small pelvis]

Experience with 62 combined operations on patients with nonorganic new growths of the true pelvis is discussed. They accounted for 33.3% of 227 radical interventions undertaken for this disease. The ages of the patients ranged from 4 months to 64 years. Ten patients were admitted after exploratory laparotomies. Benign new growths were diagnosed in 14 and malignant new growths in 48 patients. Different variants of operative approaches were used. Most frequently the tumor was resected together with bones, iliac vessels, genitalia, and urinary bladder. Various complications were noted in 39 patients who were operated on. Hemorrhage was the most frequent and menacing complication--in 26 patients. Two patients died. Recurrences were found in 8 of a group of 60 patients discharge from the clinic. After combined operations for malignant nonorganic tumors of the true pelvis 3-year survival was 36.0%, 5-year survival was 29.4%.

[Transcatheter arterial embolization therapy in cases of recurrent and advanced pelvic cancer--estimation by Cox's proportional hazard model]

From April 1983 through September 1988, transcatheter internal iliac arterial embolization therapy (TAE) using Gelfoam particles was performed in 36 patients with recurrent pelvic cancer and 18 patients with advanced pelvic cancer. The tumor showed complete response (CR) to the therapy in seven patients, partial response (PR) in 18, minor response (MR) in five, and no change (NC) in 24 patients, with the response rate (CR + PR) of 46.3%. Univariate analysis, using Kaplan-Meier estimates and log-rank test, revealed that overall survival was related to performance status (p = 0.0001) and tumor reduction by TAE (p = 0.0008). Similarly, a multivariate analysis, using Cox's proportional hazard model, revealed a strong relationship between prognosis and performance status and tumor reduction by TAE. These results show that both good general condition and tumor reduction by TAE are significant characteristics for the prognosis of recurrent and advanced pelvic cancer treated by TAE.

The role of pelvic exenteration for sarcomatous malignancies

Pelvic exenteration, although performed most frequently for recurrent squamous cell carcinoma of the cervix and vagina, has been used in selected patients with pelvic sarcoma. Nine patients with various histologic types of sarcoma treated by pelvic exenteration are reported. During this 23-year time period, 46 patients with sarcoma were evaluated for possible exenteration. Patients with embryonal rhadomyosarcoma (sarcoma botryoides) were excluded because these pediatric tumors are now treated with less radical operative procedures, plus radiation and chemotherapy. Six patients had exenteration as primary treatment, and three patients had exenteration as secondary treatment. Four patients developed recurrent disease (mean 5.2 months), and all four died of disease. Five patients were alive at 5 and 10 years, for an absolute survival of 55%. All three patients with mixed mesodermal tumors died of recurrent disease, compared with 83% survival for patients with other sarcoma types. Pelvic exenteration may play a limited but important role in the therapy of pelvic sarcoma.

High energy neutron therapy programme at the Douglas Cyclotron Centre, Clatterbridge Hospital

Preliminary results are reviewed on the outcome of patients treated within two randomized studies with either p(60) + Be-neutrons or photons. Since April 1987 67 patients have been treated of which twelve have been included in a randomized study on head and neck cancer and 40 on pelvic cancer. The clinical treatment planning is presented in detail and discussed. The results presented are considered to be very preliminary, so that no attempt has been made to analyse and discuss them in detail.

Intra-operative radiation therapy in the treatment of pelvic malignancies: a preliminary report

Local control of advanced pelvic malignancies, particularly when complete surgical resection is not feasible, is often impeded by dosage limitations in radiation therapy and the intolerance to radiation of normal tissues. This is a preliminary report on the feasibility of improved local control in pelvic malignancies treated by intra-operative radiation therapy, as a radiation boost, in addition to conventional surgical resection and external beam radiation therapy. Fifteen gynaecological malignancies (five cervix, five uterus, four ovary, and one vulva) from Rush Medical College and the University of Navarre, as well as 36 other pelvic malignancies (32 colorectal, 4 genito-urinary) from Rush Medical College were reviewed. All tumours were advanced or recurrent, and all patients were felt to be at high risk of local failure. IORT was administered at a dose range of 10-26 Gy. Our data suggest that the probability of local control improves when IORT is used for primary and for microscopic disease, when the tumour is at least partially resectable, and when the total dose given in IORT and external beam radiation exceeds 70 Gy.

Is percutaneous nephrostomy for hydronephrosis appropriate in patients with advanced cancer?

Twenty patients with advanced pelvic malignancy and secondary hydronephrosis underwent percutaneous nephrostomy between July 1982 and October 1986. Improvement in renal function occurred in 17 patients (85 percent), and survival ranged from 4 days to 2 years. Median survival was 13 weeks, and 55 percent of the patients required multiple hospitalizations for urosepsis. In addition, 55 percent required multiple tube changes. Thirty-five percent of the patients never left the hospital and an additional 35 percent spent less than 6 weeks at home before they died. Median survival for eight patients with primary cancers most frequently associated with carcinomatosis was 7 weeks, and 63 percent of these patients died during hospitalization. The factors of limited survival, significant morbidity, in-hospital mortality, and poor quality of life should be considered before recommending percutaneous nephrostomy in patients with advanced cancer.

[Clinical evaluation of implantable drug delivery system (Port-A-Cath) in cancer chemotherapy]

Intra-arterial infusion chemotherapy has become widely accepted in the multimodal treatment of many malignant tumors. We have used Port-A-Cath, which is an implantable drug delivery system, for regional infusion therapy in cancer chemotherapy since April 1984 and made a study protocol for evaluation of safety, usefulness and reliability. Twenty-two patients with pancreatic and intra-pelvic tumors have been treated with this method. Drugs of this series were adriamycin and mitomycin-C, using intermittently and 5-Fluorouracil continuously with or without radiotherapy. In localized unresectable adenocarcinoma of pancreas, the median implanted days of Port-A-Cath was 139 days and the median survival from implantation was 212 days. On the other hand, in advanced or recurrent intra-pelvic tumors, the median implanted day was 274 days and median survival time from implantation was 583 days. One case developed skin necrosis at the implanted area, and three had infections which were able to be managed. The findings suggest that Port-A-Cath assures safety and good quality of life in cancer patients because of the freedom of movement, normal physical appearance and barriers to infection due to subcutaneous placement.

Malignant melanoma. Treatment with high-dose combination alkylating agent chemotherapy and autologous bone marrow support

Nineteen patients with metastatic malignant melanoma were treated with 20 courses of high-dose combination alkylating agent chemotherapy and autologous bone marrow support. All 20 treatment courses were evaluable for toxic reactions and 17 of 20 courses were assessable for response. Twelve of the 20 courses were given at the phase 2 dose per square meter of cyclophosphamide (5.625 g), cisplatin (165 mg), and carmustine (600 mg). Marrow reconstitution occurred with a median time to recovery of 21 and 24 days for more than 500 neutrophils and more than 20,000 platelets, respectively. The overall response rate was 65%, with one patient achieving a complete response with chemotherapy alone. Ten additional patients achieved partial responses following chemotherapy, of which three were subsequently rendered disease free by surgical resection of single areas of residual tumor. Two of these patients are alive and disease free more than 22 months following chemotherapy and one remains relapse free. The median survival for responding patients was 15.2 months and 8.6 months for the entire group.

Composite pelvic resection. An approach to advanced pelvic cancer

The definition of resectability has changed in the management of advanced pelvic malignancy. Most tumors previously considered unresectable can be removed by a function-preserving composite resection of the pelvis. We have performed resection in 55 such patients. Most had posterior pelvic tumors (47 patients), had previously undergone irradiation, and required a combined sacral resection. Included were patients with recurrent or locally advanced rectal cancer (32 patients), epidermoid cancer of the anorectum (seven patients), and primary pelvic malignancies (eight patients). Most had good functional recovery. The five-year actuarial survival rate was 23% (five of 25 patients survived longer than 51 months) in the patients with resected rectal cancer and 14% (one of seven patients) in the patients with resected anorectal carcinoma. Five of eight patients with primary tumors survived longer than 48 months. Lateral pelvic resections were done for five tumors that involved the ileum or ischium, and anterior resection was done in three patients for malignancy that involved the symphysis and rami. Four of these patients were living three to six years after surgery. The overall mortality rate was 7% (four of 55 patients). Composite pelvic resections can provide good local control with preservation of limb function in most patients with primary or secondary tumors of the bony pelvis.

Primary site as a prognostic variable for children with pelvic soft tissue sarcomas

From 1974 to 1983 we treated 16 children between 1 and 16 years old for soft tissue sarcoma arising in the pelvis, bladder or prostate. An incisional biopsy was obtained in every patient. Each child then was treated with a combination chemotherapy program, incorporating vincristine, actinomycin D and cyclophosphamide with or without doxorubicin, cis-platinum and etoposide. Of the 16 patients 13 (81 per cent) also received radiation therapy. In 8 children with urinary obstruction or hematuria sarcomas arose in the bladder or bladder-prostate region, including 7 who had localized tumors and 1 who had lung metastases at diagnosis. The median tumor diameter in these patients was 5 cm. Of these 8 patients 3 eventually required total cystectomy and prostatectomy to eradicate persistent local tumor, and 6 are alive and remain free of recurrent sarcoma for 1 to 9 years after initiation of therapy. The 8 other children had a pelvic mass at diagnosis, which arose adjacent to but outside of the bladder or prostate, and 2 had lung metastases at diagnosis. The median tumor diameter in these patients was 15 cm. Only 3 of these 8 children are alive and remain free of sarcoma for 1 to 8 years after initiation of therapy. In only 1 of these children was complete tumor excision ever possible despite the use of local radiation therapy and aggressive chemotherapy. Sarcomas arising in the bladder-prostate region are found when relatively small, perhaps because they soon produce overt signs, and they appear to have a better prognosis than those arising in the retroperitoneum-pelvis outside the bladder. Better treatment strategies are needed for the latter group of tumors that often are locally uncontrollable.

Adult neuroblastoma. Report of three cases and review of the literature

Adult neuroblastoma is an uncommon malignancy. The authors report three additional cases and review the 39 reported cases in the world literature. Presentation in the abdomen is the most common; a high rate of lower limb presentation is also observed. Incidence is equal between sexes with median age of presentation of 34 years. Survival is greatest after surgical intervention (median, 20.5 months) compared with no surgery (median, 12.5 months). Chemotherapy may benefit individual patients but does not have a major impact on survival. Radiotherapy is indicated for localized, inoperable primaries or painful metastases. The survival rates of this group of patients parallels that of childhood neuroblastoma, Stage III-IV.

Rhabdomyosarcoma: the Stanford experience using a TNM staging system

Seventy-four patients with rhabdomyosarcoma were initially staged according to the Intergroup Rhabdomyosarcoma Study (IRS) grouping classification and then retrospectively using a TNM staging system based on the initial clinical extent of disease. The TNM system includes T1, tumor confined to site or organ of origin; T2, regional extension beyond the site of origin; N0, normal lymph nodes; N1, lymph nodes containing tumor; M0, no evidence of metastases; and M1, distant metastases. All patients received combination chemotherapy, and more than 90% received radiation therapy as part of their initial treatment program with curative intent. Fifty-three of 74 patients (72%) were group III according to the IRS system, indicating unresectable or gross residual tumor. A more uniform distribution was achieved using the TNM system. Freedom from relapse (FFR) was 43% and the actuarial survival rate was 47% for the entire study group at 10 years. All but one relapse occurred within 3 years of initial diagnosis, and only three of 38 relapsed patients were salvaged. All TNM stage I patients are surviving disease free. Among patients having stages II, III, and IV disease by the TNM system, FFR was 53%, 26%, and 11%, and the survival rates were 47%, 36%, and 33%, respectively. Thirty-two of 74 patients (43%) had evidence of lymph node involvement at presentation, and 28 (88%) of these had primary lesions that extended beyond the site of origin (T2 primary). Histologic subtype and primary site had little impact on outcome in a multivariate analysis, and T stage was identified as the single most significant covariate correlated with survival; a model composed of both T stage and M stage was the best one for predicting relapse. The presented data support a study using a prospectively assigned TNM staging system based on the initial clinical extent of disease for use in future therapeutic trials.

[Transcatheter arterial embolization therapy of recurrent pelvic cancer]

Embolization of the internal iliac artery with Gelfoam partiles was performed in 14 patients with recurrent pelvic cancer between February 1984 and February 1985. The sites of treatment were the uterus, urinary bladder, sacral mass, vulva and obstrator muscle. Full-dose radiotherapy had been performed as the primary treatment in 10 cases. According to Karnofsky's criteria, the therapeutic effect of embolization was rated as 1-A or better in 71.4% of the patients. Regarding complications of embolization therapy, two cases of vesicovaginal fistula were noted. All these results suggest that embolization is a useful method for the treatment of recurrent pelvic cancer, especially after radiotherapy.

Pelvic exenteration

Sixty-eight patients at the University of Illinois, Cook County, and the West Side Veterans Administration hospitals underwent pelvic exenteration for advanced pelvic malignancies during the 15-year period from 1969 to 1984. Thirty-two had colorectal cancers, eleven cervical, seven bladder, and six vulvar; in twelve the cancers were in miscellaneous pelvic sites. Forty-five exenterations were done with intent to cure, and twenty-three for palliation of patients with bulky, necrotic tumors that had caused symptomatic fistulae, local sepsis, chronic bleeding, or severe localized pain. The total 30-day postoperative mortality was 4.4% (3/68). The 5-year survival rate of patients who underwent curative exenteration was 33% (median 27 months). Pelvic exenteration appears to be a feasible surgical procedure for a variety of advanced malignancies as well as for palliation of severely symptomatic patients.

Medical management of intestinal obstruction in patients with advanced malignant disease. A clinical and pathological study

A clinical and pathological study was made of 40 patients with intestinal obstruction due to far-advanced abdominal and/or pelvic malignant disease. Surgical intervention was feasible in only 2 cases. The remaining 38 patients were managed medically without intravenous fluids and nasogastric suction. Obstructive symptoms such as intestinal colic, vomiting, and diarrhoea were effectively controlled by drugs.

Complications of pelvic exenteration

This report is based on a retrospective review of 104 patients who had undergone pelvic exenteration for advanced malignancy over a 29-year period (1956 to 1984, inclusive). Fifty-one patients (49%) developed major complications of the operative field involving the gastrointestinal tract (fistula or obstruction), the urinary tract (fistula, infection, or obstruction), or the wound (abscess, dehiscence/necrosis, or hemorrhage). No association was identified between the complication rate and organ of primary disease, extent of disease, tumor histology, or extent of resection. Patients receiving pelvic radiotherapy prior to exenteration had a much higher complication rate (39/58, 67%) than patients having had no radiotherapy (12/46, 26%). Reconstruction of the irradiated pelvis after exenteration by omental flap, colonic advancement, and/or myocutaneous flaps decreased the complication rate from 82% (27/33) to 48% (12/25). The operative mortality of pelvic exenteration was 2.9% and the actuarial five-year survival rate was 27%.

Pelvic exenteration--Medical College of Georgia experience

Between 1959 and 1983, 42 pelvic exenterations were performed. The early experience shows a rather high surgical mortality; 7 out of the first 10 cases. This has been improved with experience and better pre- and postoperative care. There has been no postoperative mortality in the last 20 patients. The combined published reports show an operative mortality of 15-17%.

Pelvic exenteration: a 15-year experience in a general metropolitan hospital

Between June, 1966, and June, 1981, 92 pelvic exenterations were performed by gynecologic oncologists at Jackson Memorial Hospital/University of Miami Medical Center. The decrease in postoperative morbidity and mortality and the improved 5-year survival rate probably were related to improvement in hospital facilities and more refined surgical techniques. Urinary and gastrointestinal complications occurred with equal frequency during the period of study and were more common in patients who had received previous radiation therapy. On the basis of our experience, recommendations to decrease gastrointestinal and urinary complications further are presented.

Clinical (stage III) as compared to subclinical intrapelvic extrauterine tumor spread in endometrial carcinoma: a clinical and histopathological study of 175 patients

One hundred and seventy-five patients with endometrial cancer, seen in the Norwegian Radium Hospital from 1960 to 1977, had tumor extension outside the uterus but not outside the true pelvis. One hundred and eight of these patients had clinical stage III disease and in 67 patients, originally classified as stage I or stage II, the intrapelvic extrauterine tumor spread was first detected at surgery or at histopathological examination of the operation specimen. The 40% 5-year-actuarial survival of the latter group differed significantly from the 16% found in clinical stage III (P less than 0.001). This must be largely contributed to the fact that radical surgery could only be performed in 13% of the clinical stage III group as compared to 70% in the group of patients with subclinical extrauterine disease. Surgical eradication of all macroscopic tumor was of major prognostic importance for patients with clinical stage III, resulting in an actuarial 5-year survival of 41%, nearly identical to 42% for the group of patients with subclinical extrauterine tumor extension. Adjuvant progestagen therapy seemed to be of some benefit, but the need, however, for a more effective systemic treatment, possibly using cytotoxic drugs, is evident.

Improved tolerance with two radiation fractions per day for treatment of abdominal and pelvic malignancies

When major volumes of the abdomen are the tolerable dose is frequently limited by the tolerance of the small intestine and other gastrointestinal tissues. In an attempt to increase the tolerable dose, a twice-daily, 5 day/week fractionation scheme was used. One hundred and thirty-nine patients were started on treatment for abdominal and pelvic malignancies, of whom 124 received the planned dose, usually in the prescribed time. Fifty-five hundred to 6000 rad in about 8 weeks was administered to large volumes of the pelvis and abdomen, frequently with "boost" radiation to 7500 rad to limited volumes. Ninety percent of the patients were able to complete treatment without interruption. In 90% of all cases there were no late radiation-related complications. The acute reactions and late complications have been comparable to those incurred when total doses 20-30% less are administered with one fraction per day. The survival rates of these patients indicates a probable improvement in therapeutic ratio. The physical techniques, areas treated, and time-dose sequence are described. A detailed analysis by primary organ, patient characteristics, performance status, types of complications, cause of death, and survival characteristics is presented.

Pelvic Ewing's sarcoma. Advances in treatment

In a study of eighteen patients with pelvic Ewing's sarcoma who were treated with a multidisciplinary approach, chemotherapy was effective in controlling systemic spread of the tumor. Surgery coupled with improved methods of chemotherapy provided results that were statistically superior to those obtained with radiation and chemotherapy alone in control of the local pelvic lesion. A twofold increase in the survival rate was seen at a median follow-up of thirty-six months in the patients who had the resection. Our results suggest that pelvic Ewing's sarcoma is best treated by initial chemotherapy, followed by local wide marginal resection of the pelvic lesion coupled with perimeter radiation therapy and concluded with additional chemotherapy. Survival rates of patients with pelvic Ewing's sarcoma may then approach the excellent survival rates of patients with lesions in more favorable anatomical locations.

Abdominosacral approach for retrorectal tumors

The relative rarity and anatomical position of retrorectal tumors may lead to difficulty in diagnosis and surgical treatment. The clinical features and management of 20 such tumors (chordoma 8, neurilemmoma 3, teratoma 3, hemangiopericytoma 1, chondrosarcoma 1, osteosarcoma 1, dermoid 1, lipoma 1, and undifferentiated sarcoma 1) have therefore been reviewed. Low back or sacral pain was present in 18 patients and, although all tumors were palpable on rectal examination, pain had been present for a median of 12 months before diagnosis. Mean tumor size was 9.4 cm (range: 2.5-17 cm). Sacral bone destruction was demonstrated radiographically in all chordomas and three sarcomas, but in none of the benign tumors. Three patients had undergone previous partial removal of their tumors. Surgical resection was carried out using a combined abdominal and transsacral approach in 13, a transsacral approach in the right lateral position in four and transabdominally in three. There was one operative death following secondary operation for chbrdoma. Four of 12 patients with malignant tumors are alive and well at seven months to eight years. One died of a myocardial infarct without recurrence at 11 years. For small benign tumors, the right lateral position permits maximal flexibility for resection either by the transsacral, transabdominal or a combined approach. For bulky or malignant tumors, a combined abdominal transsacral approach in the right lateral position permits vascular control and provides good exposure for protection of vital structures and wide resection.

Reassessment of circle tube nephrostomy in advanced pelvic malignancy

The dilemma created for and presented to the urologist by the combination of a patient with increasing uremia from advanced pelvic malignancy and a referring physician frustrated by the situation is solved best by individual decisions appropriate for each case. Urinary diversion should be reserved for the occasional circumstance when reasonable life expectancy approaches 6 months or more. Drainage by circle tube nephrostomy provides minimal trouble for patient and physician, while providing excellent relief from the obstructive uropathy. In this series of 20 patients the average survival was 5.3 months. An attempt to assess the quality of life after diversion by circle tube nephrostomy is made.

Long term survival after compound hemipelvectomy

Three patients survived free of disease ten and one-half, ten and almost six years, respectively, following compound hemipelvectomy for a variety of tumors. Each patient had been operated upon previously at least three times, but the tumors were still well localized despite the propensity for local infiltration or growth. In addition to the lower extremity and the ipsilateral pelvic bones, varieties of organs were resected. In one patient with chondrosarcoma of the pelvis, there was a local recurrent mass and, in another with adenocarcinoma of the appendix, a solitary pulmonary metastasis. Both of these lesions were successfully resected, and the patients remained free of disease nine and four and one-half years, respectively, after resection of the recurrent lesions. The third patients had carcinoma of the penis with metastases in both groins; carcinoma of the breast devedeveloped nine and one-half years after hemipelvectomy. The two younger patients were fitted with prostheses, and all three adjusted fairly well physically and psychologically to their disability. Frequently, the huge size of these tumors, the infiltration of many contiguous structures and, possibly, other features known to be associated with a bad prognosis make them appear to be incurable. We suggest that slowly growing tumor which remain localized for a long time can be controlled if adequately excised, possibly because they may be associated with strong systemic immunity. The extremely few such patients who may be encountered in surgical practice ought, therefore, to be recognized as potentially curable and treated accordingly, despite the often formidable risk or technical problems at operation and the resultant postoperative disabilities.

The surgical technique for hindquarter amputation. A report of 19 cases

The surgical technique for hindquarter amputation is described in a step-by-step manner. Since 1955 we have performed 19 such operations for eradication of malignant bone and soft tissue tumors in the pelvic, hip and upper thigh regions. Three hindquarter amputations were performed for local recurrence following initial wide excision. The overall 5-year survival rate for our 19 patients was 42.1 per cent. Malignant soft tissue tumors appear to have a much better 5-year survival rate than malignant bone tumors (60 per cent vs. 22.2 percent). We feel that surgery is still the treatment of choice. However, in the presence of proper indications, chemotherapy and radiotherapy should be added to surgery in order to prolong survival time and save lives.

Pelvic exenteration for advanced pelvic malignancies

Our experience of 76 pelvic exenterations for advanced pelvic malignancies is presented, with emphasis on the results and complications. The overall operative mortality rate of 14% is acceptable, and a five-year survival rate of 20% has been achieved. The procedure has a definite role to play in the management of advanced but otherwise localized pelvic malignancies.

Late effects of x irradiation in patients treated for metropathia haemorrhagica

We have previously reported on the causes of death among 2,068 patients treated with X irradiation for metropathia haemorrhagica at three Scottish radiotherapy centres between 1940 and 1960 (Doll and Smith, 1968). This cohort of women has now been followed up for a further seven years. 500 (24 per cent) women have now died, 78 (3-8 per cent) have emigrated and 25 (1-2 per cent) could not be traced. The numbers of deaths from different causes have been compared with the numbers expected in a population of similar age and sex exposed to the Scottish national mortality rates over the same period. An excess of deaths from leukaemia (seven observed, 2-3 expected) and of cancers of the heavily irradiated sites (59 observed, 40-1 expected) continues to be observed five or more years after treatment. There is no indication of any change in the excess death rate, due to cancers of sites in the radiation field, with time since treatment up to at least 20 years after the radiation exposure. Over the same period the number of deaths from cancer of the breast was below expectation (ten observed, 22-3 expected) and no increased mortality from coronary disease was seen (102 observed, 100-9 expected). The mean dose of radiation to the bone marrow has been determined for each woman ant it is estimated that the excess rate of leukaemia in the first 20 years after treatment is about 1-1 per million women per year per rad. This figure is in accord with the estimates derived from the survivors of the atomic bomb explosions in Hiroshima and Nagasaki and among patients with ankylosing spondylitis treated with X irradiation. However, the finding of no excess risk of leukemia among women treated with irradiation for cancer of the cervix (Hutchison, 1968) suggests that the simple assumption of a linear dose-response relationship for leukaemia is incorrect, at least when high doses of radiation are delivered to a small volume of marrow.