Biomedical subjects

B W Corn

Publications and source records attributed to B W Corn.

At least 37 records · Page 2Linked to original sources

PubMed1998

Stage T3 prostate cancer: a nonrandomized comparison between definitive irradiation and induction hormonal manipulation plus prostatectomy.

OBJECTIVES: At our institution, a Phase II trial using androgen suppression followed by surgery was completed for men with Stage T3 disease and negative laparoscopic nodal dissection. We recently reported the unfavorable biochemical outcome of that experience. Because that analysis did not include a control group of irradiated patients, the current project was undertaken to compare that Phase II experience with clinical Stage T3 patients treated at our institution with definitive irradiation during an overlapping period of time. METHODS: The Phase II trial included 21 patients with T3 tumors and negative laparoscopic nodal dissections treated by 4 months of neoadjuvant hormonal treatment (leuprolide +/- flutamide) prior to radical prostatectomy. Patients who declined to participate in the study or those judged ineligible by virtue of poor surgical risk were treated with definitive irradiation (n = 29). Although the radiation portals were shaped with multileaf collimation, no attempt was made to design "conformal fields." The median dose was 68 Gy (range 66 to 72) delivered in conventional fractionation. Biochemical failure after prostatectomy was defined as prostate-specific antigen (PSA) levels exceeding 0.2 ng/mL. Biochemical failure after irradiation was defined as a rise in absolute level of PSA greater than 1.5 ng/mL, or two consecutive elevations of PSA on sequential measurements, even if the absolute level was less than 1.5 ng/mL. RESULTS: In univariate comparison, the freedom from biochemical relapse rate at 3 years was 41% for irradiated patients and 23% for those treated by hormones combined with surgery (P <0.05). In a multivariate regression model controlling for the prognostic factors of baseline PSA, age, clinical substage, Gleason score, and treatment modality (induction androgen suppression + prostatectomy versus radiotherapy), only low baseline PSA independently predicted improved freedom from biochemical recurrence (P = 0.04). CONCLUSIONS: The combination of induction hormonal treatment followed by radical prostatectomy offered no advantage over irradiation alone in this single institutional experience. Notwithstanding, the majority of men treated by definitive radiotherapy manifested biochemical failure. More innovative strategies such as conformal irradiation (either alone or combined with androgen ablation) and radiation dose escalation should be pursued to optimize outcome for this unfavorable group of patients.

Age Factors↗

PubMed1998

Durable efficacy of early postoperative radiation therapy for high-risk pT3N0 prostate cancer: the importance of radiation dose.

OBJECTIVES: To determine the durable efficacy of early postoperative radiation therapy (RT) in patients with pT3N0 prostate cancer who were at an increased risk of biochemical failure. We also evaluated the long-term benefit derived from using higher RT doses. METHODS: Seventy-nine patients with pathologic Stage T3N0 prostate cancer and high-risk postoperative features underwent RT within 6 months after surgery. No patient received prior hormonal therapy. Fifty-nine patients had positive surgical margin, 29 had pathologic seminal vesicle invasion, and 27 had persistently elevated postoperative prostate-specific antigen (PSA) levels. Freedom from biochemical relapse (bNED) was defined as an undetectable (less than 0.2 ng/mL) PSA level. Median follow-up time was 39 months, and the median radiation dose was 64.8 Gy. All patients were followed for at least 2 years to be considered biochemically controlled. RESULTS: Patients receiving adjuvant RT for an undetectable pre-RT PSA level had a 3-year bNED rate of 90%, compared with 44% for those receiving salvage RT for a detectable level (P < 0.0001). In the group of adjuvant patients, RT doses more than 61.2 Gy resulted in a 3-year bNED rate of 90% compared with 64% for those receiving a lower dose (P=0.015). The salvage patients irradiated with a dose of 64.8 Gy or greater had a 3-year bNED rate of 52% compared with 18% for those irradiated with lower doses (P=0.048). Severe late RT-related complications were infrequent and did not correlate with dose. CONCLUSIONS: In patients with high-risk pT3N0 prostate cancer, an RT dose response may exist. Although some studies suggest limited durable efficacy for early postoperative RT, our data suggest that RT doses of 64.8 Gy or more appear superior to prevent future biochemical failures. A prospective randomized study evaluating a postoperative RT dose response is warranted.

Aged↗

PubMed1998

Atypical and malignant meningiomas: an outcome report of seventeen cases.

Limited data are available concerning the outcome of patients with atypical and malignant meningiomas. We therefore analyzed the outcome of seventeen patients with meningiomas (9 atypical; 8 malignant) at Thomas Jefferson University Hospital between 1973 and 1996. Strict adherence to the 1993 WHO criteria for the typing of CNS tumors was maintained. The median potential follow-up period for all patients was 87 months. The age at diagnosis ranged from 22 to 72 (mean 51.8 years). There were 5 males and 12 females. The mean tumor diameter was 4.45 cm. Of the 16 cases where the extent of surgical resection was known, 4 were partial and 12 were complete resections. Six patients (35%) had dural or cortical invasion by tumor. Fifteen patients received postoperative megavoltage photon irradiation (mean 61 Gy). One of these fifteen pts. received an additional 20 Gy with Au-198 implantation and 1 received post-radiation chemotherapy for recurrent disease. The overall survival rate for all patients at 5 and 10 years were 87% and 58% respectively. The 5- and 10-year survival rates for atypical meningiomas were 87% and 58%; for malignant meningiomas the survival rates were 60% and 60% respectively. Five patients (30%) have died. Three of these 5 patients initially received less than 54 Gy to the tumor bed and have died of recurrent disease. Local disease progression was documented in 11 patients (65%) after surgery and in 3 patients (18%) after radiation. There was an improvement in performance status in 3 (18%) patients with a decline and no change seen in 1 (6%) and 13 (77%) respectively after receiving radiation. There appeared to be no difference in survival in patients as a function of dural or cortical invasion. Long term survival is possible for patients with atypical and malignant meningiomas treated with surgery and post-operative radiation. We are unable to distinguish a difference in outcome between these two pathological entities. Dural and cortical invasion were not associated with a decrease in survival. In addition, improved tumor control and survival may be associated with increased radiation dose.

Adult↗

PubMed1998

Patterns of tumor progression after radiotherapy for low-grade gliomas: analysis from the computed tomography/magnetic resonance imaging era.

Postoperative radiotherapy for low-grade gliomas has been shown in retrospective series to improve survival, compared with surgery alone. To determine the proper radiotherapy treatment volume and dose, an understanding of the patterns of failure with current radiotherapy techniques is necessary. We studied 30 consecutive patients who had a pathologic diagnosis of low-grade nonpilocytic glioma treated in our department between 1975 and 1994. Before radiotherapy, 5 patients underwent biopsy, 22 had subtotal resection, and 3 had gross total excision. All had pre- and posttreatment computed tomographic (CT) or magnetic resonance imaging (MRI) scanning. Megavoltage radiotherapy was delivered to shrinking partial (22 patients) or whole-brain (8 patients) fields. Median dose was 59.4 Gy (range, 46.4-64 Gy) in 1.8- to 2-Gy fractions. Median follow-up was 44 months (3-215 months) for the cohort and 105 months for survivors. For the entire series, 5-year overall survival and relapse-free survival rates were 50% and 41%, respectively. Sixteen patients (53%) progressed at a median of 30 months. At the time of failure, 71% (5 of 7) of pathologically evaluated tumors were of high grade. Recurrence originated within the field in all patients. Higher 5-year overall survival and relapse-free survival rates were associated (p < 0.001) with preradiotherapy functional status 1 versus functional status 2 through 4 (60% vs. 0% and 55% vs. 0%, respectively). Seizure as initial presentation was favorable over other symptoms (5-year overall survival, 64% versus 14%; p = 0.057). We conclude that 1) low-grade nonpilocytic gliomas can transform to high-grade lesions after treatment with conventional radiotherapy, 2) recurrence uniformly occurs within the treatment volume, and 3) pretreatment functional status correlates prognostically with survival. The local pattern of failure suggests that radiotherapy dose escalation within conformal fields could improve results.

Adolescent↗

PubMed1998

Concomitant irradiation and dose-escalating carboplatin for locally advanced carcinoma of the uterine cervix: an updated report.

The combination of radiotherapy and carboplatin is associated with high response rates among women who have cervical cancer. To improve control rates for patients who have locally advanced carcinoma of the uterine cervix, oncologists have explored combinations of radiotherapy and chemotherapy. Carboplatin is an analogue of cisplatin, with similar efficacy against cervix cancer and a toxicity profile that is theoretically appealing for this group of patients because it is not nephrotoxic. Fifteen women with International Federation of Gynecology and Obstetrics (FIGO) stages IB2 through IIIB or recurrent carcinoma of the cervix were treated with megavoltage irradiation and weekly intravenous carboplatin (7 women, 60 mg/m2; 8 women, 90 mg/m2). Response was documented among all patients treated at 60 mg/m2 (three complete responses, four partial responses) and in 6 women treated with 90 mg/m2 (four complete responses, two partial responses). The two nonresponders in the series presented with recurrent glassy cell carcinoma of the cervix. All patients completed the planned course of therapy without the need for treatment interruption. At 60 mg/m2, one dose of carboplatin was withheld because of grade 2 thrombocytopenia. At 90 mg/m2, one case of grade 2 leukopenia was documented. The leukocyte counts remained within normal limits for all 3 patients who were irradiated through extended portals that encompassed the paraaortic nodes (2 women, 60 mg/m2; 1 woman, 90 mg/m2). To date, 2 of 7 patients treated at the lower dose level have died of disease (one local progression and distant failure at 11 months, one distant failure alone at 6 months). The remaining patients treated at 60 mg/m2 are alive at a median of 24 months (range, 21-37 months). Among those treated at the higher dose level, 1 patient is alive with local and distant failure at 14 months, and 1 woman succumbed to local and distant disease at 4 months. The remainder are alive at a median follow-up of 6 months (range, 2-10 months). The regimen was unsuccessful in salvaging women with recurrent glassy cell carcinoma. We conclude that the combination of radiotherapy and carboplatin can be safely delivered at both of the chemotherapy schedules studied. The regimen should not be offered to women who have recurrent glassy cell tumors. To prove the efficacy of this approach, phase III testing should be considered that compares the combination of agents to irradiation alone.

Adult↗

PubMed1997

A prospective, randomized study addressing the need for physical simulation following virtual simulation.

PURPOSE: To accurately implement a treatment plan obtained by virtual or CT simulation, conventional or physical simulation is still widely used. To evaluate the need for physical simulation, we prospectively randomized patients to undergo physical simulation or no additional simulation after virtual simulation. METHODS AND MATERIALS: From July 1995 to September 1996, 75 patients underwent conformal four-field radiation therapy planning for prostate cancer with a commercial grade CT simulator. The patients were randomized to undergo either port filming immediately following physical simulation or port filming alone. The precision of implementing the devised plan was evaluated by comparing simulator radiographs and/or port films against the digitally reconstructed radiographs (DRRs) for x, y, and z displacements of the isocenter. Changes in beam aperture were also prospectively evaluated. RESULTS: Thirty-seven patients were randomized to undergo physical simulation and first day port filming, and 38 had first day treatment verification films only without a physical simulation. Seventy-eight simulator radiographs and 195 first day treatment port films were reviewed. There was no statistically significant reduction in treatment setup error (>5 mm) if patients underwent physical simulation following virtual simulation. No patient required a resimulation, and there was no significant difference in changes of beam aperture. CONCLUSIONS: Following virtual simulation, physical simulation may not be necessary to accurately implement the conformal four-field technique. Because port filming appears to be sufficient to assure precise and reliable execution of a devised treatment plan, physical simulation may be eliminated from the process of CT based planning when virtual simulation is available.

Computer Simulation↗

PubMed1997

Which prognostic factors influence the outcome of patients with surgically staged endometrial cancer treated with adjuvant radiation?

PURPOSE: Despite the fact that retrospective reviews have documented pelvic failure rates ranging from 15-20% in patients with high-risk uterine-confined endometrial cancer who have received no or "inadequate" RT, the role of RT has been questioned. We sought to analyze pelvic control and disease-free survival for a large data base of women with corpus cancers managed with initial surgery followed by adjuvant irradiation. METHODS AND MATERIALS: Between 1983 and 1993, 294 patients received adjuvant postoperative RT from one of three academic radiation practices. RT consisted of vaginal brachytherapy alone in 28 patients, pelvic RT in 173 patients, pelvic RT with vaginal brachytherapy in 97 patients, and whole abdominal RT in 2 patients. Lymph nodes were evaluated in 49%. The median number of pelvic and periaortic LN in the pathology specimen were 6 and 4, respectively. Median follow up was 63 months. RESULTS: 5-year disease-free survival (DFS) rate and pelvic control rates were 86 and 95%, respectively. Patient-related, treatment-related, and tumor-related characteristics were assessed for the effect on time to relapse. Unfavorable histology, older age, and capillary space invasion were univariately associated with decreased DFS and pelvic control. Pathologic Stage II patients had significantly worse DFS than Stage I patients. Multivariate analysis revealed that age, capillary space invasion, and histology were jointly predictive of disease free survival. CONCLUSION: The excellent pelvic control and disease-free survival of patients with uterine-confined disease in this series suggest that adjuvant RT should continue for patients with high risk disease. This analysis of a large group of postoperatively treated patients will provide a basis for determining alternative treatment strategies for patients who have an increased risk of disease recurrence despite RT.

Adult↗

PubMed1997

Will primary central nervous system lymphoma be the most frequent brain tumor diagnosed in the year 2000?

BACKGROUND: There has been a dramatic increase in the diagnosis of primary lymphoma of the brain during the past decade, prompting speculation that it may become the most frequently diagnosed tumor of the central nervous system by the year 2000. The current analysis drew from the updated Surveillance, Epidemiology, and End Results (SEER) database to establish projections for the incidence of brain lymphoma. The study also attempted to determine whether increased incidence rates are attributable to the increasing incidence of acquired immunodeficiency syndrome (AIDS) and whether there is gender or age dependence. METHODS: Primary brain lymphoma case data and population census data for calculating incidence rates for the period 1973-1992 were obtained from the SEER program. In an attempt to determine the contribution of AIDS to the increasing incidence of the disease, separate analyses were performed with and without the inclusion of never married men (a high risk group for the development of AIDS). Separate analyses were also performed within the San Francisco SEER registry because a higher incidence of AIDS-related cancers has been documented in this geographic region. Finally, a piece-wise linear model (using one regression line until 1982 and another regression line from 1982 onward) was used to predict incidence rates for the year 2000. RESULTS: During the period of study, the incidence rates of brain lymphoma increased more than 10-fold, from 2.5 cases per 10 million population in 1973 to 30 in 1991-1992 (chi-square trend, 17.76: P < 0.0001). These increased incidence rates were independent of age and gender. The incidence rates of primary brain lymphoma did not differ significantly when comparing the San Francisco registry with the remainder of the SEER database for any comparison that excluded never married males. However, when the analysis included never married males, a statistically significantly higher incidence rate of primary central nervous system lymphoma was observed among San Franciscans compared with age-matched controls from the remainder of the SEER database. In the year 2000, the projected incidence rate of brain lymphoma would reach 51.1 per 10 million population and 118.2 per 10 million population, with never married men excluded and included, respectively. These incidence rates would still fall below the corresponding projections for glioma and glioblastoma multiforme. CONCLUSIONS: There continues to be a significantly increasing incidence of brain lymphoma that is independent of age and gender. Indirect evidence implicates the AIDS epidemic as a contributor to this trend. Although the rate of increase in the incidence of non-Hodgkin's lymphoma of the brain is higher than for peripheral non-Hodgkin's lymphoma and other glial tumors, brain lymphoma is not projected to surpass glial tumors as the most frequently diagnosed intracranial malignancy by the year 2000.

Age Factors↗

PubMed1997

Palliation of AIDS-related primary lymphoma of the brain: observations from a multi-institutional database.

PURPOSE: To catalogue the presenting symptoms of patients with AIDS who are presumed to have primary central nervous system lymphoma (PCNSL). To document the palliative efficacy of cranial irradiation (RT) relative to the endpoints of complete and overall response for the respective symptoms. METHODS: An analysis of 163 patients with AIDS-related PCNSL who were evaluated at nine urban hospitals was performed. These patients were treated for PCNSL after the establishment of a tissue diagnosis or on a presumptive basis after failing empiric treatment for toxoplasmosis. All patients were treated between 1983 and 1995 with radiotherapy (median dose-fractionation scheme = 3 Gy x 10) and steroids (>90% dexamethasone). Because multiple fractionation schemes were used, prescriptions were converted to biologically effective doses according to the formula, Gy10 = Total Dose x (1 + fractional dose/alpha-beta); using an alpha-beta value of 10. RESULTS: The overall palliative response rate for the entire group was 53%. In univariate analysis, trends were present associating complete response rates with higher performance status (KPS > or = 70 vs. KPS < or = 60 = 17% vs. 5%), female gender (women vs. men = 29% vs. 8%), and the delivery of higher biologically effective doses (BED) of RT (Gy10 > 39 vs. < or = 39 = 20% vs. 5%). In multivariate analysis of factors predicting complete response, both higher KPS and higher BED retained independent significance. A separate univariate analysis identified high performance status (KPS > or = 70 vs. KPS < or = 60 = 71% vs. 47%), and young age (< or = 35 vs. > 35 = 61% vs. 40%) as factors significantly correlating with the endpoint of the overall response. In multivariate analysis, high performance status and the delivery of higher biologically effective doses of irradiation correlated significantly with higher overall response rates. CONCLUSION: Most AIDS patients who develop symptoms from primary lymphoma of the brain can achieve some palliation from a management program that includes cranial irradiation. Young patients with excellent performance status are most likely to respond to treatment. The delivery of higher biologically effective doses of irradiation also may increase the probability of achieving a palliative response.

Acquired Immunodeficiency Syndrome↗

PubMed1997

External beam irradiation for choroid metastases: identification of factors predisposing to long-term sequelae.

PURPOSE: To improve overall quality of life, palliative treatments should attempt to minimize associated complications while effectively controlling specific symptoms. We reviewed our experience treating posterior uveal metastases with external beam radiotherapy (EBRT) to determine the complication rate and to identify the relationship between patient, tumor, or treatment-related factors and the development of ocular complications. METHODS AND MATERIALS: 483 consecutive patients (pts) (578 eyes) were diagnosed with intraocular metastatic disease from solid tumors between 1972-1995. Of these, 233 eyes (188 pts) had lesions of the posterior uveal tract and received EBRT. Median follow-up time was 5.8 months (range: 0.7-170.0 months). Follow-up information regarding the development of complications was documented for 230 eyes. Complete EBRT details were available for 189 eyes. Seventy-two percent of the patients received 30.0-40.0 Gy in 2.0-3.0 Gy fractions. Biologically effective dose (BED) was calculated to allow meaningful comparisons between various fractionation regimens and total doses. Concurrent chemotherapy and/or hormonal therapy was used for 101 eyes (44%). RESULTS: Median BED was 61 Gy3 (range, 6.7-105 Gy3), and 80% of treated eyes received BED 50-70 Gy3. EBRT energies included photons (70%), 60Co (19%), electrons (6%), mixed energies (3%), and orthovoltage (2%). Lens-sparing techniques were used in 136 eyes (71%). At last follow-up 28 eyes (12%) developed one or more significant complications, including cataracts (16 eyes), radiation retinopathy (6 eyes), optic neuropathy (5 eyes), exposure keratopathy (5 eyes), and neovascularization of the iris (4 eyes). Two eyes developed narrow-angle glaucoma, and one of these required enucleation. On univariate analysis, Caucasian race (vs. Black/Hispanic, p = 0.03), increased intraocular pressure at diagnosis (>21 mmHg, p = 0.02), and diagnosis by biopsy (vs. no biopsy, p = 0.03) predisposed toward the development of complications. Factors not correlated with complications included BED (p = 0.18), energy type (p = 0.81), lens-sparing technique (versus whole globe, p = 0.57), and concurrent systemic treatment (p = 0.60). The small number of complications did not support a multivariate analysis. CONCLUSIONS: Despite the employment of a variety of EBRT treatment techniques and the proximity of choroidal metastases to radiosensitive structures, significant complications of palliative EBRT were infrequent. Although complications do occur, they are related to host factors and do not appear to be a function of irradiation parameters. We conclude that the potential benefits of vision and globe preservation after palliative EBRT outweigh the small risk of treatment induced complications.

Adult↗

PubMed1997

Effect of edema on the post-implant dosimetry of an I-125 prostate implant: a case study.

PURPOSE: To investigate the effect of post-implant edema on the CT-based calculation of the total dose delivered by an I-125 prostate implant. MATERIALS AND METHODS: CT scans of a transperineal I-125 prostate implant were obtained 1 and 39-days post-implant. Changes in the prostate dimensions were determined from changes in the spatial distribution of the I-125 seeds. The total dose delivered to the target volume was computed from each CT scan, and the results compared. RESULTS: The volume of the prostate decreased by approximately 17% during the 38-day interval between the first and second CT scans. As a result, the radiation dose computed from the second CT scan was 13% higher. CONCLUSION: Post-implant edema can cause a significant underestimation of the radiation dose delivered by an I-125 prostate implant. Similar analysis should be carried out among a larger cohort of patients to confirm or refute these observations.

Aged↗

PubMed1997

Tumor bed brachytherapy with a mesh template: an accessible alternative to intraoperative radiotherapy.

BACKGROUND AND OBJECTIVES: Locally advanced and recurrent malignancies often require adjuvant radiotherapy to achieve tumor control. We report our experience with a technique that uses an intraoperatively placed mesh template for the delivery of radiotherapy. METHODS: from 1988 to 1996, 14 patients were treated with tumor bed brachytherapy using this mesh technique. Sites of involvement included the head and neck region (n = 6), abdomen/pelvis (n = 4), retroperitoneum (n = 3), and the lower extremity (n = 1). During surgery, plastic catheters were evenly placed within a mesh template (Vicryl or Marlex), which was positioned in the tumor bed. The catheters were afterloaded with radioactive sources once the final pathology had been determined and the patient required limited nursing care. Radiation dose was titrated to the surgico-pathologic findings (e.g., margin status). RESULTS: All of the patients tolerated the procedure without experiencing acute or chronic sequelae. The median survival time was 13 months. Local control was achieved in 11 of 13 evaluable patients, with an actuarial local control of 82% at 6 months. CONCLUSION: Tumor bed brachytherapy with a mesh implant is a practical technique to improve tumor control and warrants further investigation.

Abdominal Neoplasms↗

PubMed1997

Easy method for defining intracranial target volumes on orthogonal simulation films using magnetic resonance images.

A technique is described for simulating intracranial radiation fields. The method involves the projection of images from magnetic resonance (MR) scans to orthogonal simulation radiographs. This approach often can supplement and occasionally obviate the need for computerized tomographic (CT) assisted treatment simulation for co-planar beam arrangements in brain irradiation. Because magnetic resonance imaging can be performed in virtually any plane and is routinely carried out in sagittal and coronal planes, transferring tumor volumes to orthogonal simulation films using this technique can be done simply and accurately. The method employs an inexpensive photographic enlarger to superimpose sagittal MR scans on the lateral skull simulation films. Tumor volumes along with other structures of interest are treated onto the film and appropriate fields and blocks are contoured. The technique is performed easily in conjunction with routine simulation sessions, provided that the appropriate MR images are available. It is most suitable for planning treatment of tumors located at midline (e.g., medulloblastomas, craniopharyngiomas, brainstem gliomas, germinomas, etc.). The technique has also been used to verify the accuracy of CT-assisted treatment planning. With relatively minor modifications, eccentric tumors also can be accurately planned, and although we have restricted our description to brain tumours, the technique may be extrapolated to tumors in other sites.

Brain Neoplasms↗

PubMed1997

Intra- and perioperative complications associated with tandem and colpostat application for cervix cancer.

PURPOSE: The purpose of this study was to chronicle the acute morbidity associated with the implantation of tandems and colpostats in women with carcinoma of the cervix; to determine factors that predispose to the development of such complications; and to assess whether the use of ultrasound allowed the apparatus to be safely implanted in women at relatively high risk for perforation of hollow viscous organs. METHODS: A database from two Philadelphia institutions was used to assess the aforementioned factors among 143 tandems/colpostats inserted into 100 women with cervix cancer. Twenty patients had insertion under ultrasound guidance because of stenotic cervical os, fibrosis from external-beam irradiation, indeterminate orientation of endometrial cavity axis, or previous perforation. Univariate and multivariate analyses were performed to identify predictors of intra- and perioperative complications. RESULTS: Intraoperative complications occurred in 7 of 143 placements (5%). These included uterine perforations (n = 4), vaginal lacerations (n = 2), and one instance of bladder perforation. Only older age, whether entered as a continuous or a dichotomous variable, was associated statistically with these complications. Perioperative complications (e.g., fever, bowel obstruction, exacerbation of chronic obstructive pulmonary disease, cardiac complication) occurred in 54 of 143 implanted women. In univariate analysis, older age and underlying chronic obstructive pulmonary disease (COPD) appeared to be associated with perioperative complications. A multivariate analysis showed that underlying COPD predisposed to perioperative complications during the first implant and that age over 60 years independently predicted for complications during any implant. CONCLUSIONS: Intraoperative complications are relatively rare events. Ultrasonography seems to allow safe intrauterine insertion of the tandem despite the selection of difficult cases for this adjunctive imaging tool. Patient age over 60 years independently predicts for perioperative complications. COPD predicts for perioperative complications during the first but not the second implant, implying that physicians are able to optimize the medical management of pulmonary disease to allow a second implant to be performed more safely.

Adult↗

PubMed1997

The relationship of local and distant failure from endometrial cancer: defining a clinical paradigm.

PURPOSE: Recently, statistical methods have been developed to rigorously assess the relationship between local and distant failures. Such methodology has successfully been applied to a variety of tumors including those arising in the prostate, breast, and cervix. To date, no published data are available to generate a hypothesis to characterize the relationship between local and distant failure for endometrial cancer. The present analysis was undertaken to determine the effect of locoregional control on subsequent metastatic dissemination among women with pathologically staged endometrial cancer treated by hysterectomy followed by adjuvant radiotherapy. METHODS: The series consisted of 394 patients with FIGO stages I-III endometrial cancer who were surgically staged prior to irradiation [median external beam dose 45 Gy +/- brachytherapy (median vaginal surface dose, 30 Gy)]. The duration of follow-up ranged from 2 to 151 months, with a median of 62 months. Multiple factors were evaluated to determine the associations with distant relapse including FIGO pathological stage, grade, histopathologic subtype (adeno vs papillary/papillary-serous/clear cell), depth of myometrial penetration, age, and local disease status. Time-dependent survival models were generated to assess the influence of local failure on distant metastases. RESULTS: For the entire series, the 5-year actuarial rates of local and distant failures were 9 and 20%, respectively. Women who failed locally had nearly a fourfold risk of failing distantly compared to those who remained locally controlled (P = 0.02). Moreover, the earlier a local failure developed (e.g., within 1 year vs within 3 years), the more likely it was to be associated with distant metastases (P < 0. 05). The univariate correlations of other factors with the 5-year rate of freedom from distant relapse also disclosed significant associations for grade, histology (adenoca vs papillary/papillary-serous/clear cell), and FIGO path stage. In multivariate analysis, only local control, low grade (grade 1 and 2), and early pathological stage were independently related to the likelihood of achieving freedom from distant relapse. CONCLUSIONS: Distant dissemination of endometrial cancer may develop secondary to local failure. Optimization of local control is therefore necessary if long-term cure is to be achieved. The limits of the current database cannot establish whether local failure is a cause of distant spread or a high-risk marker for metastases; however, ongoing national cooperative trials may resolve this controversy.

Actuarial Analysis↗

PubMed1997

National trends in the surgical staging of corpus cancer: a pattern-of-practice survey.

OBJECTIVE: To survey general gynecologists regarding the nature of surgical staging of corpus cancer as practiced in the United States. METHODS: A survey tool was designed to ascertain issues related to surgical staging of corpus cancer among gynecologists in the United States. The survey elicited data pertaining to the demographics and practice characteristics of the respondents. The questionnaire was sent to 700 practicing gynecologists selected randomly from the ACOG membership list. RESULTS: Responses were obtained from 227 physicians; however, only 193 could be analyzed. Most of the respondents classified themselves as general gynecologists (93%) and nonacademicians (90%). In a typical year, 60% evaluated fewer than five patients with corpus cancer. A minority of respondents carry out surgical staging of their patients, which includes total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO), removal of pelvic and para-aortic lymph nodes, and cytologic evaluation of peritoneal fluid. No uniformity was observed regarding the numeric definition of an appropriate "sampling" (median 5, range 1-25) or "dissection" (median 10, range 1-40) of lymph nodes. Most respondents would not return a corpus cancer patient to the operating room to carry out lymph node dissection if a referring colleague had performed TAHBSO but had not removed the nodes. In such a scenario, private practitioners were approximately three times less likely to reoperate on lymph nodes than academic physicians. CONCLUSION: Complete surgical staging is not performed by most physicians caring for women with corpus cancer. The relatively high proportion of nonresponders and nonevaluable responses suggests that these results should be corroborated by other investigators.

Female↗

PubMed1997

Prostate imaging may not be necessary in nonpalpable carcinoma of the prostate.

OBJECTIVES: Stage T1c carcinoma of the prostate is defined as a nonpalpable carcinoma (NPC-P) that is not visible by imaging and is identified by needle biopsy performed because of elevated prostate-specific antigen (PSA) concentrations. The purpose of this study was to define the incidence of normal findings on transrectal ultrasound (TRUS) and/or endorectal coil magnetic resonance imaging (EMRI) among patients with NPC-P, as well as to investigate the value of differentiating patients with Stage T1c disease from all other patients with NPC-P. METHODS: The records of 2211 patients diagnosed with prostate carcinoma between 1988 and 1995 were reviewed to identify 291 men with NPC-P. TRUS and EMRI reports were analyzed with regard to the presence and laterality of hypoechoic nodules or low-signal areas reported on T2-weighted images, respectively. Ninety percent of patients (n = 262) had at least six prostate biopsies, 185 patients (64%) underwent both TRUS and EMRI, 224 (77%) had TRUS, and 251 (86%) had an EMRI study. RESULTS: Results were considered normal in 101 (47%) of 214 patients undergoing TRUS, in 58 (23%) of 249 undergoing EMRI, and in 22 (12%) of 185 undergoing both TRUS and EMRI. For the side of the prostate with positive biopsy results, correlation with imaging abnormalities was better for EMRI than for TRUS (39% versus 24%). There was no significant difference in mean PSA value, distribution of Gleason score, or unilateral versus bilateral positive biopsy results among patients with normal versus abnormal findings on both TRUS and EMRI. CONCLUSIONS: (1) Only 12% of men with NPC-P have no TRUS or EMRI abnormalities, fulfilling the criteria for Stage T1c prostate carcinoma. (2) Those patients with Stage T1c disease do not differ from patients with NPC-P up-staged by TRUS or EMRI, with regard to pretreatment PSA levels, Gleason scores, and the probability of having bilateral rather than unilateral positive biopsy results. (3) The value of classifying patients with NPC-P into Stage T1c versus higher stages of prostate carcinoma on the basis of imaging should be questioned.

Adenocarcinoma↗

PubMed1997

Respiration-induced motion of the kidneys in whole abdominal radiotherapy: implications for treatment planning and late toxicity.

PURPOSE: Whole abdominal radiotherapy (WAR) has potential utility in the management of several malignancies. The limited radiation tolerance of the kidneys is an important consideration in the design of WAR fields. Although renal blocking is standard for WAR, few guidelines exist in the literature to factor respiration-induced kidney motion into the design of these blocks. METHODS: Radiographs were obtained to measure kidney excursion under forced respiratory conditions in eight patients (14 visualized kidneys). Intravenous contrast was administered and AP films were obtained at maximum inspiration and expiration. Renal excursion was measured relative to a horizontal reference line at the bottom of the L3 vertebral body. The kidney position on the actual treatment simulation film was also determined using this technique. Treatment isodose distributions through the kidneys were obtained for a sample patient using phantom measurements and two blocking schemes: AP/PA and PA only. These provided quantification of the actual dose received by the kidney in a typical WAR treatment. RESULTS: In the worst case scenario, the left kidney block required an additional 10 mm above and 15 mm below the renal silhouette on the simulation film in order to account for all phases of respiration. The corresponding values for the right kidney were 2 mm and 19 mm, respectively. The dose received by the kidney under the center of the block was 20% of prescribed using AP/PA blocks and 50% of prescribed using PA blocks only. However, portions of 'blocked' kidney received up to 90% of the prescribed dose with either technique. CONCLUSIONS: Although kidney motion under forced respiratory conditions is not representative of typical treatment conditions, the data highlight the possibility of renal movement during treatment. This is particularly important in light of the significant dose (20 to 50%) delivered to the kidney under the center of the kidney block of typical treatments. Given the potential for overdosage of this critical organ, careful prospective documentation of renal function is warranted in patients receiving WAR.

Abdomen↗