Stage I Seminoma of the Testis: Long Term Results and Toxicity with Adjuvant Radiotherapy

Aims and background

Pure testicular seminoma has historically been treated with post-orchidectomy radiation therapy with excellent results. Recently, several aspects of the treatment of stage I seminoma have been questioned. We assessed long-term results and toxicity of patients with pure testicular seminoma treated at the Department of Radiation Oncology of S. Chiara Hospital, Trento.

Methods

From 1953 to 1987, 102 patients with stage I pure testicular seminoma were given megavoltage irradiation with curative intent. All patients had a minimum follow-up of 3 years (maximum 37 years, median 13 years). They received a mean para-aortic/pelvic dose of 33.07 Gy (range 23.70-45.20 Gy) with different doses and fields reflecting the change in techniques over a long period of time.

Results

The cause-specific actuarial survival at 30 years was 99% and crude survival 67%. One patient had an out-field relapse (inguinal) after a few months and was cured with radiotherapy and chemotherapy. Another patient relapsed with widespared metastases and died after 1 year of progressive disease. Early toxycity was mild and the treatment was well tolerated. Late side effects were reported in 8/102 patients.

Conclusion

In our series adjuvant radiation therapy resulted in cure rates corresponding to those reported in the literature. The 30-year actuarial survival of 99% was extremely good and the toxicity of the treatment was mild. Post-orchidectomy radiation to the para-aortic and ipsilateral pelvic nodes is a safe and effective method of preventing recurrences and is currently to be considered the treatment of choice in stage I testicular seminoma.

Breast Cancer Estrogen and Progesterone Receptors: Associations with Patients' Clinical and Epidemiologic Characteristics

A total of 1095 patients with operable breast cancer and en-rolled in a randomized clinical trial were analysed for estrogen (ER) and progesterone (PgR) receptor content of their primary tumor, and the relationships between steroid receptor status and several epidemiologic characteristics were studied. The proportion of ER+ and median ER levels increased with age: compared to women younger than 40, those aged 66 or more were approximately three times more likely to have an ER+ tumor (OR = 3.0, 95% C.I. = 1.6–5.7). This difference tended to be more marked after comparison between patients with ER > 100 fmol/mg protein and ER- within the same age groups: OR = 7.04, 95 % C.I. = 2.89–17.12. No association emerged between age and PgR. ER status and concentrations were independent of menopausal status after adjustment for age, whereas the proportion of PgR+ and PgR levels were significantly lower in postmenopausal patients of the same age. The distribution of ER and PgR profiles was similar in relation to family history of breast cancer, reproductive events and other selected epidemiologic characteristics of the patients.

Primary non-Hodgkin's lymphoma of the female genital tract

Genital tract lymphoma is a rare disease; information on diagnosis, treatment and outcome are limited. We report on eight patients affected by non-Hodgkin's lymphoma of the genital tract, five from the cervix, two from the vagina and one from the vulva collected between 1987 and 1998. Age at presentation ranged from 36 to 82 (median 67) years. The commonest initial symptom was vaginal bleeding, post coital in 1 patient. Three patients complained of vescical symptoms. Ann Arbor classification was stage IAE for 6 patients. Histology, according to the IWF, was either intermediate grade (4 patients), or high grade (3 patients), not evaluable in one case. Seven patients were treated with chemotherapy (anthracycline based in four) followed by pelvic radiotherapy in five; one patient received irradiation alone. Five patients are currently alive and free of disease with follow-up ranging from 8 to 126 months. Based on our experience in this series, we support a management scheme of combination chemotherapy and radiotherapy for patients with non-Hodgkin's lymphoma of the genital tract.

Hyperfractionated radiation in combination with local hyperthermia in the treatment of advanced squamous cell carcinoma of the head and neck: a phase I-II study

Twenty-seven patients with cervical metastases from squamous cell head and neck tumours were treated with hyperfractionated XRT (total dose 69.60-76.80 Gy, 1.2 Gy b.i.d. five times a week) combined with a total of two to six sessions of superficial external HT. Acute local toxicity was mild; as major acute side effects, only one ulceration was recorded. No severe late side effects were observed. Late toxicity was similar to that observed in our previous studies with the combination of heat and radiation. Nodal complete response was observed in 77% of patients, partial response was observed in 15% of patients and no change was observed in 8% of patients. Five-year actuarial nodal control was 64.5 +/- 19% and 5-year actuarial survival was 24 +/- 10%. The treatment of nodal metastases from head and neck tumours with the combination of HT and hyperfractionated XRT is feasible with an acceptable acute and late toxicity profile.

[Hyperthermia and palliative radiotherapy for sarcoma]

The current treatment of bone and soft tissue sarcomas consists of a multimodality approach based on the combination of surgery, radiotherapy and, more rarely, chemotherapy. Since local recurrence is an important cause of failure and morbidity, new treatment modalities such as hyperthermia, have been proposed to try to overcome this problem. July, 1982, to June, 1993, twelve patients (15 lesions) with recurrent or locally advanced sarcoma, were treated at the Department of Radiation Oncology, S. Chiara Hospital-Trento (Italy) with irradiation and hyperthermia. Radiation therapy was delivered with different techniques using palliative or radical doses (24-70 Gy) and different fractionation schedules. Local microwave hyperthermia was given in 2-9 sessions (mean 4.7). Eight (53.3%) complete responses and 4 (26.6%) partial responses were observed. Three lesions recurred at 11, 13, and 30 months; 5-year actuarial local control was 25.4 +/- 13.4%. Actuarial 5-year overall survival was 49.5 +/- 16.4%. Toxicity was mild: two superficial necroses, spontaneously healed after few months, were observed; local pain during hyperthermic treatment was recorded in 15% of sessions. Lesion volume and total radiation dose appeared to be correlated with the response. In our experience, the combination of radiotherapy and hyperthermia seems to be a valuable therapeutic approach in the treatment of locally advanced or recurrent sarcomas.

[Radiotherapy of T1N0 neoplasms of the glottis. Analysis of the parameters that influence local control]

Treatment and tumor-related parameters were reviewed in 176 patients with T1N0 carcinoma of the glottic larynx submitted to primary radiation therapy from 1980 to 1992. Our aim was to analyze local control and treatment-related toxicity. Over-all local control rates at 10 years were 88.3% with irradiation alone and 94.5% after salvage surgery (larynx preservation: 91%). Verrucous histology was a negative factor affecting local control and anterior commissure involvement exhibited only a negative trend but had no statistical significance. Among treatment-related factors, local control was 76.5% after split-course and 91.1% after continuous-course irradiation (p < 0.05). With continuous-course irradiation, the total dose influenced local control only for single of 2 Gy (local control rates were 69% with 60 Gy and 93% at > or = 64 Gy; p < 0.05), but not for single doses of 2.25 Gy and total doses ranging 56.25-65.25 Gy (local control failed in 55 patients). Early and late complications did not increase with single doses > or = 2.25 Gy. Our current policy in T1N0 nonverrucous glottic carcinoma is to use a single fraction of 2.25 Gy and a total dose ranging 56.25-63 Gy according to tumor size, with a continuous course.

Long-term cosmetic outcome and toxicity in patients treated with quadrantectomy and radiation therapy for early-stage breast cancer

Breast conservation treatment followed, if useful, by adjuvant therapy is the treatment of choice in early breast cancer. Late cosmetic outcome and toxicity are important in comparing conservative treatment to mastectomy. We reviewed the records of 225 patients treated from 1981 to 1988 with a median follow-up of 74 months (range 12-156 months). Cosmetic results, either reported by the physician (82.4%) or by the patients themselves (81.5%), were generally excellent or good, and tended to decline with time (69 and 75.5%, respectively). Toxicity was mild with arm edema (14.6%) being the most frequent symptom. No severe toxicities were observed. We conclude that overall cosmesis has been acceptable in this series and that a low rate of long-term toxicity can be expected with this conservative approach.

Beam modifying devices in the treatment of early breast cancer: 3-D stepped compensating technique

A 3-D compensating technique utilizing stepped brass filters to ensure an adequate dose distribution in the breast after conservative surgery is described. No compensation for lung inhomogeneity is applied. These compensators are part of a procedure which also involves the use of a rotatable half-beam block (HBB) and of an individualized immobilization cast. Results of patient dosimetry show a good agreement with dose prescription in the target volume (measured dose/prescribed dose = 100.9% +/- 1.8% at the reference point). Phantom dosimetry is discussed.

[Radiotherapy, radiotherapy combined with surgery, radiotherapy combined with chemotherapy in the treatment of carcinoma of the pyriform sinus. A retrospective study]

A rectrospective analysis was performed of the results of 104 consecutive patients with carcinoma of the pyriform sinus, who underwent radiation therapy. Thirty-four patients underwent radical surgery and postoperative radiation therapy (group 1); 36 patients received radical radiation therapy alone (group 2); neoadjuvant chemotherapy was administered prior to full-dose radiation to 20 patients (group 3); 14 patients received palliative radiation therapy (group 4). Loco-regional control and survival rates at 5 years were 60.4% and 34.3% in group 1, 23.8% and 23.8% in group 2, 17.5% and 23.8% in group 3; no patients in group 4 survived at 5 years. Patients in group 1 experienced significantly better survival and local control than those in groups 2 and 3. No differences were observed between groups 2 and 3. Loco-regional recurrence was the main cause of failure in group 2 (69.4%) and 3 (70.0%). In group 1, 20.3% of cases developed distant metastases. Overall 5-year survival rate was 23.7%, confirming the poor prognosis of this disease. These results provide further support to the need of improving prevention and early diagnosis to improve both results and outcome in patients with carcinoma of the pyriform sinus.

[Radical radiation therapy of carcinoma of the rhinopharynx: analysis of 80 cases]

From 1976 to 1987, 98 patients affected with nasopharyngeal carcinoma were observed at the Oncology Center, Trento, Italy. Eighty of them were treated with radical radiation therapy (average total dose: 6432 Gy, range: 5500-7400 Gy) on primary tumor and positive neck nodes. The clinically negative neck received 5000 Gy. Each dose ranged from 180 to 250 Gy. Fifty-nine patients were treated with the split-course technique with an interval of about 15 days after receiving 4000 cGy. The patients were 60 males and 20 females, their age ranging 17-81 years (mean: 57 years). Histology diagnosed squamous cell carcinoma in 15 cases and undifferentiated carcinoma in 65 cases. All patients were staged according to TNM (UICC, 1978) criteria. Ten patients were stage I/II. Complete local control was obtained in 81.3% of cases. Actuarial global survival at 10 years was 52%, actuarial relapse-free survival was 49%. Mean follow-up is 33 months (range: 4-122 months). Squamous cell carcinoma at histology and advanced nodal involvement (N2-N3) were negative prognostic factors. Six patients had a relapse in the nasopharynx and 5 in the neck; the incidence of distant failures was 20%. The most frequent mid-/long-term side-effect was xerostomia.

Neoadjuvant Chemotherapy with Vincristine, Bleomycin and Methotrexate Combined with Radiotherapy in Advanced Head and neck Squamous Cell Carcinoma

From September 1980 to August 1981, 25 patients with advanced head and neck squamous cell carcinoma were treated at the Centro Oncologico, Trento, by a chemo-radiotherapeutic combination. The treatment protocol consisted of 4–6 courses of VBM (vincristine, bleomycin and methotrexate) followed by conventional radiotherapy (65 Gy). Only to VBM responders (15 patients) were administered 10 cycles of vincristine-methotrexate. At the end of induction chemotherapy an overall response of 60 % (12 % complete, 48 % partial) was obtained. At the end of radiotherapy the responses were 52.5 % complete and 35.5 % partial, for an overall response of 88 %. The overall survival at 60 months was 8 %. This combined approach, in spite of the satisfactory immediate local response rate, does not offer advantages for survival in comparison to conventional treatment modalities.

[Burkitt's lymphoma with leukemic evolution]

An account of the clinical, histopathological and aetiopathogenetic aspects of Burkitt's lymphoma is followed by the presentation of a personal case, in which the typical clinical picture of the African form progressed to terminal leukaemia. The aetiological and pathogenetic rôle of the Epstein-Barr virus is also briefly discussed.