Search

The value of prognostic factors in patients with advanced cervix carcinoma treated by radiotherapy was assessed in a retrospective study.From January 1977 through December 1990, 261 patients (average age 60 years) were treated at the Radiotherapy Department of the University of Turin. Distribution by stage was: 142 T2b (54%), 8 T3a (3%), 98 T3b (38%) and 13 T4 (5%). 83% of the patients underwent radiotherapy alone; the total dose was 45-88 Gy in 91 patients (42%) with poor clinical conditions, 60-75 Gy in 121 (56%) and 75-80 Gy in 5 cases. 17% of the patients was treated by surgery combined with radiotherapy. The median follow-up was 50 months (minimum 2, maximum 177 months).The 5-year NED survival and local control were 42% (52% for T2b, 33% for T3 and 15% for T4). The severe (G3-G4) complication rate was very low (1.9%).In our series, the prognostic factors which significantly influenced survival in the uni-variate analysis were: advanced T stage, contemporary infiltration of parametrium and vagina, nodal status, non squamous neoplasm, younger age and the absence of brachytherapy in the radiotherapy alone protocol.

Today there is increased need for an objective comparison between the various post-total laryngectomy phonatory rehabilitation techniques. This survey involves 20 patients who, after total laryngectomy, underwent rehabilitation using the esophageal voice (n = 10) or through the application of a secondary tracheal-esophageal prosthesis (n = 10). The multivariate analysis indicated that the only phonatory parameter which differed significantly between the two types of voice was the maximum phonation time (MPT) (p0.01). The MPT was markedly longer in patients with the tracheal-esophageal prosthesis. In patients with prosthesis, the Mann-Whitney test highlighted better figures for the following parameters: MPT (p = 0.0003), GP (maximum number of words that can be read in one breath) (p = 0.009), maximum intensity level (MIL) (p = 0.019), Shimmer (p = 0.008) and noise-to harmonics ratio (NHR) (p = 0.049). Furthermore, the Spearman test proved there is a relationship between MIL and GP, and between Pitch and Shimmer. Therefore, the tracheal-esophageal prosthesis seems to offer better phonatory energy and phonatory duration for every breath. However, these methods of objective inquiry need to be further developed so that comparison-among the different authors and among the different rehabilitation methods-can be made easier than it is now.

January, 1977, to December, 1990, 311 patients with stage IB-IIA cervix carcinoma were treated at the Radiotherapy Department of the University of Turin. The distribution by stage was: 232 T1b (74.6%) and 79 T2a (25.4%). One hundred and eighty-nine patients (77% T1b-23% T2a) underwent preoperative radiotherapy, 63 patients (58% T1b-42% T2a) radiotherapy alone and 59 (85% T1b-15% T2a) postoperative radiotherapy. The first group of patients was treated according to three treatment protocols, based on different surgical procedures. During the median follow-up period of 86 months (82.6% of the patients underwent a minimum 3-year follow-up), 55 locoregional relapses (17%) and 21 extrapelvic metastases (7%) were observed. The 5-year NED survival rate and local control was 80%. The prognostic factors which significantly influenced survival in the univariate analysis, were: disease stage (p.01), age (p.05), the period between first symptom and therapy (p = .01), treatment protocols (radiotherapy combined with surgery versus radiation therapy alone: p.05), residual disease after brachytherapy (p.01), nodal status (p.00001). In the radiotherapy alone group, the total dose influence on survival was not statistically significant (p = .12). In our series, histology and surgical procedures did not seem to influence prognosis. In the multivariate analysis, treatment protocol, age and residual disease after brachytherapy did not influence the prognosis, whereas the total dose of radiotherapy, pain (as first symptom) and Wertheim-Meigs surgery approach are prognostic factors. Severe late-effects were 17: 13 in the radiotherapy plus surgery protocol and 4 in the radiotherapy alone protocol. The incidence of major complications seems to correlate with surgical impact.

A carcinoma of the base of the tongue is diagnosed with difficulty and therapy offers a poor clinical prognosis. Between November 1988 and April 1993 45 patients were evaluated (38 men and 7 women, mean age 60 years). These patients were in poor clinical conditions and advanced clinical stage. Surgical treatment alone or in association with radiotherapy was employed in 17 patients. In the remaining patients radiation therapy alone or associated with chemotherapy was employed. Three-year overall actuarial survival was 39.5% and 3-year NED survival was 21%. Certain prognostic factors were evaluated: T stage, lymph nodes, TNM staging, extension to near anatomical areas and treatment. A Cox multivariate regression analysis revealed that clinical N stage was significant for prognosis (3-year overall actuarial survival was 76.9% for NO and 28% in subjects with clinical nodes). Subjects with neoplasm extension to pharyngo-laryngeal area could have better prognosis and, a finally, patients treated with surgery alone or in association with other treatment would achieve better local control than others.

Cholangiocarcinoma at the confluence of the hepatic ducts (Klatskin tumor) is a slowly growing malignancy with early onset of symptoms and poor outcome since surgery allows radical resection in only a minority of cases. Percutaneously placed biliary stents offer a good palliation, but tend to obstruct after 6-8 months; then, retreatment requires exchange of the endoprosthesis or establishment of a permanent external-internal biliary drainage which offers, in some patients, a relatively long survival. Percutaneous intraluminal HDR brachytherapy might be a valid alternative as a definitive therapy or as a method to keep metallic stents patent for a long time. Five patients with hilar cholangiocarcinoma, diagnosed by means of ultrasound, Computed Tomography, percutaneous transhepatic cholangiography and transluminal biopsy, underwent double percutaneous external-internal biliary drainage. Dummy sources were introduced into the drainage catheters to allow dose distribution planning. The stepwise progression of the miniaturized high activity Iridium source inside the applicators, introduced into the drainage catheters, was controlled and monitored by a computer equipped with dedicated software. In the radiotherapy bunker, using the remote loading technique, percutaneous intracavitary high dose rate brachytherapy was delivered at the rate of 750 cGy per fraction, prescribed at 1 cm from the center of the catheter, once a week, for 4 weeks. Nevertheless, only 4 of 5 patients underwent the complete treatment. In one case, radiation treatment was discontinued after the first session because of digestive bleeding from a duodenal ulcer, supposingly as a consequence of the decubitus of a catheter tip. CT demonstrated rapid progression of the disease with neoplastic spread to the omentum and gallbladder wall thickening; a gallbladder malignancy was then suspected and the patient was no more eligibile for brachytherapy. Subsequently, Carey-Coons endoprostheses were inserted to prevent post-actinic strictures and removed after three months. After completing radiation therapy, control cholangiograms demonstrated in all cases improvement of neoplastic strictures. The first two patients we treated show no signs of tumor recurrence at 4 and 1 months, respectively, after endoscopic removal of the stents. The third patient is still bearing 2 Carey-Coons endoprostheses to be removed after 3 months. The last patient with supposingly partial success of bracytherapy, was treated with two Strecker nitinol stents.

Between 1985 and 1989, 19 patients with mycosis fungoides were treated by Total Skin Electron Therapy (TSET). Overall and disease-free survival at 3 years were 72% and 40%. The complete remission (CR) rate was 100% in patients with plaque and 33.3% in those with tumor masses; patients with negative nodes had a 90% CR rate whereas in those with adenopathy the rate was 55%. Overall and disease free survivals were also correlated with these factors.

The authors report their experience on the treatment of carcinoma of the oral tongue and floor of the mouth with interstitial brachytherapy, alone or in combination with external irradiation. One hundred and fifty patients were treated; among these, 116 with brachytherapy alone, 34 with combined treatment. The five years local control in those patients treated with brachytherapy alone was 72.5% in T1, 61.2% in T2 and 35% in T3; in those patients treated with external irradiation and brachytherapy the global five years control was 42.5%. The global five years survival was 64% in the patients treated with brachytherapy alone and 48% in the patients treated with combined therapy.

The authors conducted a retrospective study on 99 patients with malignant tumors of the major salivary glands, who had been treated by radiotherapy between 1976 and 1986: 86 cases of parotid tumors and 13 cases of submandibular gland tumors. Only 28 tumors (28%) were T1-T2, N0-N1. Local control, 3-5 and 8-year survival rates, and complications were considered. Radiation therapy alone was performed on 19 patients (19%), while combined surgical and radiation therapy was performed on 80 patients (80%). The results of radiation therapy alone and combined with surgery are discussed. Loco-regional disease control was obtained in 9 out of 19 patients (47%) by irradiation alone, and by combined irradiation and surgery in 60 out of 80 cases (75%). Distant metastases developed in 23 out of 99 patients (23%). Loco-regional metastases were the most frequent cause of death (20 out of 55 cases: 36%). Severe complications were extremely rare. The results demonstrate not only the advantages of combined treatment but also the value of radiotherapy alone in the treatment of tumors of the major salivary glands.

After a brief review of the literature, the results of the treatment by radiation therapy in 218 patients with tonsillar region carcinoma are reported. The patients were treated at the Turin University Radiotherapy Department (131 cases) and at the Radiotherapy Department of the Ospedale Maggiore, Novara (87 cases) from 1976 through 1984. The series included 29 T1, 88 T2, 64 T3 and 37 T4; 86 patients (40%) were N0. Only 49 patients were stages I and II (1/4 of the total). The local control (T) rate at the end of therapy was 63.5% for the overall series (139/218) ranging from 100% in T1, 72.6% T2, 54.6% T3 to 30% T4; the regional control (N) for patients with cervical lymphadenopathy was 66% (88/132). The overall 5-year survival was 38%; the 5-year disease-free survival was 35%. The 5-year survival according to T-stage was 52% for limited cases (T1-T2) in comparison to 22% for advanced ones (T3-T4). The 5-year survival for N0 stage was 55%; when neck nodes were present (N # 0) the survival was 29% after 5 years. Complications included 6 cases of trismus and 2 osteonecroses of the mandible. Second primary malignant diseases were seen in 17 cases (7.8%). The most common cause of death was failure in primary tumour control (80% of cases). In this series the results of radiotherapy of early stage tonsillar carcinomas are quite good; patients with large tumour masses fare less satisfactorily. Better results should be obtained in the future by identifying prognostic factors, monitoring potential causes of treatment failure and optimizing the radiotherapeutic treatment plan and technique.