Biomedical subjects

T Panzarella

Publications and source records attributed to T Panzarella.

At least 37 records · Page 2Linked to original sources

PubMed1998

The effects of surgery, radioiodine, and external radiation therapy on the clinical outcome of patients with differentiated thyroid carcinoma.

BACKGROUND: The aim of this study was to determine the prognostic factors for local failure and cause specific survival in differentiated thyroid carcinoma and the impact of surgery, radioiodine, and external beam radiation therapy (RT) when used as part of the initial management. METHODS: The authors reviewed the records of 382 patients with differentiated thyroid carcinoma (papillary, 262; follicular, 120) managed at the Princess Margaret Hospital (PMH) between 1958 and 1985. There were 220 patients with Stage I or II, 102 with Stage III, and 33 with Stage IV disease (according to 1987 staging criteria of the International Union Against Cancer). The median duration of follow-up was 10.8 years. Potentially important prognostic factors for cause specific survival (CSS) and local relapse free rate (LRFR) were tested by multivariate regression analysis with emphasis on treatment factors. RESULTS: For patients with papillary tumors, the 10-year CSS and overall survival were 93% and 85%, respectively; for those with follicular tumors, they were 69% and 56%. The LRFR for both histologic types were 86% at 10 and 15 years. Age >60 years, tumor size >4 cm, poor differentiation, postoperative presence of macroscopic residual disease, and presence of distant metastasis at presentation were identified in multivariate analysis as statistically significant factors for cause specific death. Age >60, tumor size >4 cm, multifocality, postoperative residuum, lymph node involvement, less extensive surgery (less than near-total thyroidectomy), and the lack of use of radioiodine were significant with regard to locoregional failure. The use of external RT was associated with more advanced local disease. There were no statistically significant differences in CSS or LRFR between patients who received RT and those who did not, even after adjustment for identified prognostic factors. In the subgroup of 155 patients with papillary histology and microscopic residuum, both 10-year CSS (100% vs. 95%, P = 0.038) and LRFR (93% vs. 78%, P = 0.01) were higher for patients given RT than for those not given RT. The 33 patients with macroscopic residual disease who received postoperative RT had a 5-year LRFR of 62% and CSS of 65%. CONCLUSIONS: The prognostic factors for differentiated thyroid carcinoma have been clearly identified. Initial total thyroid ablation with total thyroidectomy and radioiodine was associated with a lower rate of local relapse, although CSS was unaffected. Many patients at risk for local recurrence received postoperative RT, which did not significantly affect the risk of local relapse or CSS in the entire group. A beneficial effect of RT was demonstrated in the subgroup of patients with papillary tumors and microscopic residuum. Patients with postoperative macroscopic residual disease appeared to benefit from RT (with or without radioiodine). A Phase III trial involving patients at high risk for local recurrence is required to assess the potential benefit of RT.

Adenocarcinoma, Follicular↗

PubMed1998

Prescribing 131Iodine based on neck uptake produces effective thyroid ablation and reduced hospital stay.

PURPOSE: The aim of this study was to determine if thyroid cancer patients with low percentage neck uptake of iodine on postoperative thyroid scans can be treated with lower doses of 131Iodine while maintaining a high ablation rate. MATERIALS AND METHODS: We reviewed the records of 58 patients with differentiated thyroid cancer treated with 131I at the Princess Margaret Hospital. The activity of 131I was prescribed based on the 48 h percentage neck uptake in postoperative thyroid scans. Patients with < or =2% uptake received 1.07 GBq, patients with 2.1-4% uptake received 1.85 GBq, patients with 4.1-6% uptake received 2.80 GBq, patients with 6.1-8% uptake received 3.70 GBq and patients with >8% uptake received 4.60 GBq. When the scan suggested cervical lymph node metastases or residual tumor, 7.40 GBq was prescribed. Follow-up scans were performed at least 5 months after 131I therapy. Successful ablation was defined as the absence of visible uptake in the neck above background. RESULTS: Forty-nine patients were included in this analysis. The ablation rate according to the prescribed activity was as follows: 1.07 GBq, 16/20 (80%); 1.85 GBq, 4/5 (80%); 2.80 GBq, 1/1 (100%); 3.70 GBq, 0/1 (0%); 4.60 GBq, 7/8 (88%); 7.40 GBq, 13/14 (93%). The ablation rate for all patients treated on the protocol was 41/49 (84%, 95% CI 70-93%). For the group treated for remnant ablation, the overall ablation rate was 28/35 (80%, 95% CI 63-92%). Twenty-two (38%) of the 58 eligible patients received 1.07 GBq as outpatients. This saved 38 hospitalization days compared to a policy of treating all patients requiring remnant ablation with 3.70 GBq. CONCLUSIONS: We conclude that patients with less iodine uptake in postoperative thyroid scans can receive lower activities of 131I, allowing a significant proportion of patients to be treated on an outpatient basis while maintaining a high ablation rate.

Administration, Oral↗

PubMed1998

Re-irradiation for locally recurrent nasopharyngeal carcinoma.

Since 1989, 17 patients have undergone re-irradiation for locally recurrent nasopharyngeal cancer (NPC). The dose currently administered externally is 39.6 Gy in 36 fractions (BID) followed by an intracavitary boost (15-20 Gy). Disease persisted in five out of five patients treated palliatively. Eleven of 12 patients treated with curative intent achieved local control.

Adult↗

PubMed1998

Management of stage II seminoma.

PURPOSE: To assess the results of treatment, patterns of failure, and prognostic factors for relapse in a contemporary cohort of patients with stage II seminoma. MATERIALS AND METHODS: From January 1981 and December 1993, 99 patients (median age, 35 years) with stage II seminoma (IIA, 41; IIB, 28; IIC, 24; IID, six) were managed at our institution. Eighty were treated with radiation therapy (RT) and 19 with chemotherapy (ChT). RESULTS: With a median follow-up of 6.7 years, the five-year overall actuarial survival was 94%, the 5-year cause-specific survival was 94%, and the 5-year relapse-free rate was 83%. Sixteen (20%) of the 80 patients treated with RT relapsed (median time to relapse, 9 months). Relapse occurred outside the irradiated area in all but two patients. Distant relapse sites included the supraclavicular fossa, bone (four patients, three with spinal cord compression), and lung/mediastinum. All 19 patients treated primarily with ChT achieved disease control and none has relapsed. The relapse rate at 5 years for patients with stage IIA to IIB was 11% (seven of 64), and 56% (nine of 16) for those with stage IIC to IID disease (P < .0001). No patient with IIC or IID disease treated with ChT relapsed as compared with 56% of patients treated with RT (0 of 14 v nine of 16, P = .002). CONCLUSION: Radiation therapy is highly effective in patients with stage IIA or IIB seminoma (89% were relapse free). In stage IIC or IID disease, although local control with RT is excellent, a 50% risk of distant relapse is unacceptable, and not all patients who relapse can be salvaged. Chemotherapy should clearly be the primary treatment in patients with stage IIC or IID seminoma.

Adult↗

PubMed1998

Economic evaluation of chemotherapy with mitoxantrone plus prednisone for symptomatic hormone-resistant prostate cancer: based on a Canadian randomized trial with palliative end points.

PURPOSE: To evaluate the economic consequences of the use of chemotherapy in patients with symptomatic hormone-resistant prostate cancer (HRPC) in the context of a previously published Canadian open-label, phase III, randomized trial with palliative end points. PATIENTS AND METHODS: The trial randomized 161 patients to initial treatment with mitoxantrone and prednisone (M + P) or to prednisone alone (P) and showed better palliation with M + P. There was no significant difference in survival. A detailed retrospective chart review was performed of resources used from randomization until death of 114 of 161 patients enrolled at the three largest centers: these included hospital admissions, outpatient visits, investigations, therapies (which included all chemotherapy and radiation), and palliative care. Cancer center and community hospital costs were calculated by using the hotel approximation method and case costing from the Ontario Case Cost Project, respectively. Cost-utility analysis was performed by transforming the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 global quality-of-life item measured every 3 weeks on trial to an estimate of utility, and extending the last known value through to death or last follow-up. RESULTS: The mean total cost until death or last follow-up by intention-to-treat was M + P CDN $27,300; P CDN $29,000. The 95% confidence intervals on the observed cost difference ranged from a saving of $9,200 for M + P (with palliative benefit) to an increased cost of $5,800 for M + P. The major proportion of cost (M + P 53% v P 66%; CDN $14,500 v $19,100) was for inpatient care. Initial M + P was consistently less expensive in whichever time period was used to compare costs. Cost-utility analysis showed M + P to be the preferred strategy with an upper 95% confidence interval for the incremental cost-utility ratio of CDN $19,700 per quality-adjusted life-year (QALY). CONCLUSION: A treatment that reduces symptoms and improves quality of life has the potential to reduce costs in other areas. Economic factors should not influence the clinical decision as to whether to use M + P in a symptomatic patient.

Canada↗

PubMed1997

Enhanced control by radiotherapy of cervical lymph node metastases arising from nasopharyngeal carcinoma compared with nodal metastases from other head and neck squamous cell carcinomas.

PURPOSE: To test the hypothesis that metastatic cervical lymph nodes arising from nasopharyngeal carcinoma (NPC) are more readily controlled with radiotherapy than comparable nodes from squamous cell carcinomas of other head and neck sites (SCC). METHODS AND MATERIALS: One hundred four NPC patients with metastatic cervical nodes (mean size of the largest node equals 4.1 cm) were randomly selected from radiation treatment files for two time periods, 1969-1976 and 1983-1988, when radiation alone was the first line treatment. Candidate controls were selected randomly from radiation treatment files of node positive squamous cell carcinomas arising from the oropharynx, hypopharynx, oral cavity or larynx who were also treated by radical radiation therapy as sole initial treatment in the 1970s and 1980s. Each NPC case was matched with a control using the size of the largest involved node as the matching criterion. The median follow-up of all 208 patients was 3 years (4.2 years in NPC cases and 1.4 years in the matched controls). For those who were alive at last follow-up, the median follow-up for both arms was 7.7 years (6.7 years in NPC cases and 10.2 years in the matched controls). Nodal control was evaluated by clinical neck examination in both arms. Nodal recurrence was defined as relapse or persistence of metastatic nodal disease from day 1 of radiotherapy treatment. RESULTS: Despite a similar mean delivered dose to involved neck nodes (52.9 Gy for the NPC group and 53.9 Gy for the matched controls), the SCC group had significantly worse nodal control with radiation when compared to the NPC group (p < 0.0001, relative risk 3.0, 95% [1.8, 5.1]). The 3-year nodal recurrence-free rate among NPC cases was 71 +/- 5%, compared to 43 +/- 5% among matched controls. CONCLUSION: The result of this study supports the hypothesis that metastatic cervical nodes from NPC are more readily controlled by irradiation than cervical nodes of similar size arising from other head and neck squamous cell carcinomas. Further study is required to explore the reasons for this apparent radiosensitivity.

Adolescent↗

PubMed1997

A comparison of different staging systems predictability of patient outcome. Thyroid carcinoma as an example.

BACKGROUND: There is no consensus regarding the comparison of staging classifications. Recently, numerous staging classifications for thyroid carcinoma have been described. This study was performed to evaluate the relative discriminating ability of these different staging systems. METHODS: A literature review was conducted to identify the available staging classifications used for thyroid carcinoma. To compare the various staging classifications, cause specific survival data from a retrospective review of 382 patients with papillary and follicular thyroid carcinoma treated at Princess Margaret Hospital were applied to the various staging classifications. The ability of these classifications to distinguish the stage groupings were compared in the following ways: 1) tabulating the numbers of patients within each stage group; 2) collapsing stage groupings into high and low risk groups and calculating mortality rates at 10 and 15 years; 3) summing observed deviations at 5, 10, and 15 years; and 4) calculating the proportion of variance explained (PVE) for each staging classification, using each classification separately as a prognostic factor in a Cox regression model. RESULTS: The application of the PVE model, the only method of the four that used statistical inference, showed no statistically significant superiority of any system over the TNM classification of the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC) in their ability to discriminate stage groupings. CONCLUSIONS: Because the TNM classification of the AJCC and UICC is universally available and widely accepted for other disease sites, the authors recommend it for all reports of the treatment and outcome of patients with thyroid carcinoma. Individual research groups also may use an alternative, validated classification to report results, provided that the outcomes are also reported using the TNM classification to facilitate comparison between different centers.

Adenocarcinoma, Follicular↗

PubMed1997

Primary lymphoma of brain: results of management of a modern cohort with radiation therapy.

PURPOSE: To assess the outcome and prognostic factors for patients with primary lymphoma of brain managed with radiation therapy between 1979 and 1988. METHODS AND MATERIALS: A retrospective review was undertaken of 49 patients referred to Princess Margaret Hospital. There were 25 males and 24 females. Median age was 60 years, with a range of 17-80 years. Tumors were located supratentorially in 35, infratentorially in 10, and both in 4 patients. Single masses were demonstrated on CT brain in 36, and multiple lesions in 13 patients. Cranial irradiation was given in 48, and 11 patients received chemotherapy. All patients in this series were immunocompetent. RESULTS: Over a follow-up range of 3-11 years of surviving patients, with a median of 6 years, 40/49 patients have died. Overall median survival was 1.4 years (17 months) and 5-year actuarial survival was 26%. Statistical analysis revealed the following significant factors: Karnofsky performance status (KPS), age, and distribution pattern of disease on presenting CT brain. Five-year actuarial survival for patients with a KPS > 60 or <60 was 56% and 10%, respectively (P = 0.01); for patients with age < 60 or >60, 5-year actuarial survival was 42% and 9%, respectively (P = 0.03); for patients with solitary or multiple lesions, 5-year actuarial survival was 30% and 15%, respectively (P = 0.04). CONCLUSIONS: We conclude that Karnofsky performance status, age, and distribution pattern on pretreatment CT of brain are significant prognostic factors in primary lymphoma of brain, and that new approaches need to be developed for these patients.

Adolescent↗

PubMed1997

Prostate specific antigen levels during radical radiation therapy and the prediction of outcome in localized carcinoma of the prostate.

There has been substantial interest in the effect of radiation therapy upon serum prostate specific antigen (PSA) levels in patients managed by radiation therapy and their ability to predict the eventual outcome. At our institute, an observational prospective longitudinal study was begun in 1989 to identify prognostic factors for biochemical relapse from among several variables, including PSA levels measured prior to treatment, during treatment, and post-treatment, and to summarize what happens to PSA levels over the course of treatment with radical radiation therapy. A total of 142 patients with adenocarcinoma of the prostate (T1-4, N0, M0) were radically irradiated (6-7 weeks) between February 1989 and January 1991. Serum PSA levels were recorded weekly during radiation therapy in 117 patients. Of these 117, weekly PSA measurements ranged in completeness from 95 to 113 cases. A number of statistical tests were performed on the data with investigative/ exploratory intent. There were 60 biochemical relapses documented in the whole group of 142 patients, with a maximum follow-up of 4.6 years and median follow-up of 3.3 years. Of the candidate prognostic variables tested by univariate analysis, the following emerged as statistically significant (i.e. P < 0.05): each of the four pretreatment factors (absolute PSA value, dichotomous PSA (normal versus above normal), T category and Gleason score); the treatment variables namely, the end-of-treatment PSA, the slope of PSA, and the absolute change in PSA from pretreatment to the end of treatment; and, among post-treatment variables, the first follow-up PSA, the absolute change in PSA from pretreatment to first follow-up, and the return to normal of an above-normal pretreatment PSA by first follow-up. The majority of these factors were then subjected to multivariate Cox proportional hazards (PH) regression analyses. The end-of-treatment PSA and T category were consistently identified as independently statistically significant factors associated with biochemical relapse. The Gleason score was selected less consistently, and never when defined on a categorical scale. Therefore, using a Cox PH model with the variables of end-of-treatment PSA and T category, both defined on a categorical scale, we developed three prognostic groups with good, intermediate and poor prognoses (chi 2 TREND = 40.7; P < 0.0001). Their 3-year biochemical relapse-free rates, for example, were: 91%, (standard error (SE) 5%); 64% (SE 9%); and 24% (SE 6%), respectively. However, substitution of the baseline value of PSA, which was also strongly associated with outcome, and using the data from all 142 patients, provided similarly distinct prognostic groups (chi 2 TREND = 41.6; P < 0.0001), with corresponding 3-year relapse-free rates of: 92% (SE 4%); 79% (SE 7%); and 30% (SE 6%). Mean weekly PSA levels measured during treatment were found to have a negatively sloping or decreasing tendency. A statistically significant decrease in PSA occurred from pretreatment to the end of treatment (t116 = 7.5; P < 0.0001); the geometric mean of the ratio of end-of-treatment PSA to PSA at pretreatment was 0.7 (95% CI 0.6-0.8). The end-of-treatment PSA and T category emerged as independently statistically significant prognostic variables predicting biochemical relapse. Using the fitted Cox PH model with these two variables, three distinct prognostic groups were identified. The results using pretreatment PSA instead of end-of-treatment PSA produced similarly distinct prognostic groups. Mean weekly PSA levels measured during treatment exhibited a decreasing tendency, and a statistically significant decrease in PSa from pretreatment to the end of treatment was observed.

Adenocarcinoma↗

PubMed1997

Autologous and allogeneic transplantation for multiple myeloma at a single centre.

We report the results of a consecutive series of patients who underwent autologous (auto) (40), allogeneic (allo) (22) or syngeneic transplantation (2) for multiple myeloma (MM) at our centre. Median age at diagnosis was 45.5 (auto) and 43 (allo) years. Most patients had stage 2 (27% auto; 27% allo) or stage 3 (62% auto; 50% allo) disease and 73% demonstrated chemosensitivity prior to transplant. Median time from diagnosis to transplant was 18.6 months (auto) and 16.4 months (allo). Standard conditioning regimens were used. Median time to neutrophil engraftment was 11 days (7-18) (auto) and 18 days (13-24) (allo) and median time to platelet engraftment was 11 days (6-60) and 18 days (13-105), respectively. Ninety-day mortality was 5% (auto) and 27% (allo). Median follow-up was 15 months (6-48) (auto) and 42 months (24-52) (allo). Three-year progression-free survival (PFS) was 17 +/- 10% (auto) and 22 +/- 9% (allo) and 3-year overall survival (OS) was 74 +/- 11% (auto) and 32 +/- 10% (allo). Autologous transplantation for MM is a safe procedure with good OS although disease progression following transplant is frequent. Allogeneic transplantation has a high procedure-related mortality and PFS comparable to autologous transplantation but OS is poor. The early mortality and high OS of autologous transplantation in MM compares favourably with both the results of allogeneic transplantation and published results of standard therapy in this retrospective analysis.

Adult↗

PubMed1997

Prognostic factors for relapse in stage I testicular seminoma treated with surveillance.

PURPOSE: We sought to identify prognostic factors predictive of disease progression in patients with clinical stage I seminoma on surveillance following orchiectomy. MATERIALS AND METHODS: Between January 1981 and December 1993, 201 patients 20 to 86 years old (median age 34) with clinical stage I seminoma were placed on surveillance following orchiectomy. The potential prognostic factors studied included age, tumor size, mitotic count, S phase fraction, ploidy, presence of small vessel invasion, syncytiotrophoblasts and tumor infiltrating lymphocytes, expression of beta-human chorionic gonadotropin and low molecular weight keratin on immunohistochemistry. RESULTS: With a median followup of 6.1 years (range 1.3 to 12.3) 31 patients had relapse for an actuarial 5-year relapse-free rate of 84.9%. The 5-year actuarial survival rate was 97.1% and the cause specific survival rate was 99.5%. On univariate analysis factors predictive of relapse were tumor size (5-year relapse-free rate 88 and 67% for tumors 6 cm. or less and greater than 6 cm., respectively, p = 0.004), age (5-year relapse-free rate 79 and 91% for age 34 years or younger versus older than 34 years, respectively, p = 0.009) and presence of small vessel invasion (5-year relapse-free rate 86 versus 69%, p = 0.01). On multivariate analysis age and tumor size were predictive of relapse, while small vessel invasion approached statistical significance. The risk of relapse in 57 patients with none of the 3 adverse prognostic factors (age greater than 34 years, tumor 6 cm. or smaller and no small vessel invasion) was 6%. CONCLUSIONS: We identified age, size of the primary tumor and small vessel invasion as important prognostic factors for relapse in patients with stage I seminoma treated with surveillance. Further followup and assessment of biological factors are needed to optimize selection of patients at a high risk for relapse who should receive immediate postoperative therapy.

Actuarial Analysis↗

PubMed1996

Ovarian irradiation and prednisone following surgery and radiotherapy for carcinoma of the breast.

Following mastectomy, patients aged 35 to 76 years with operable breast cancer underwent postoperative irradiation of the chest wall and regional lymph nodes. They were then assigned at random to receive no further therapy (NT), ovarian irradiation (R) 2000 rads in 5 days, or ovarian irradiation in the same dosage plus prednisone (R + P) 7.5 mg daily for up to five years. A total of 703 eligible patients received the randomly assigned treatment. The median follow up was 21 years with a range of 14 to 25 years. Overall, there was a delay in recurrence (p = 0.03) and survival was prolonged (p = 0.19) for patients who received R, but in neither case was the difference significant after adjusting for the multiplicity in our data. Overall, patients who received R + P experienced a significant delay in recurrence (p = 0.0003) and a significantly prolonged survival (p = 0.005), even after adjusting for multiple comparisons. In premenopausal patients who received R, the recurrence of breast cancer was delayed and survival prolonged, but not significantly. In premenopausal women aged 45 years or more, R + P therapy significantly prolonged survival (p = 0.0004), while the delay in recurrence although significant (p = 0.02) was only marginally so after allowance for multiple comparisons. No value was demonstrated for ovarian irradiation with or without prednisone therapy in postmenopausal patients. A new finding in this review was that contralateral breast cancer as the first failure was reduced by R + P compared to NT in the overall group.

Adult↗

PubMed1996

Role of radiation therapy in clinical hormonally-active pituitary adenomas.

BACKGROUND AND PURPOSE: The outcome following radiation therapy (RT) of hormonally-active pituitary adenomas was assessed. The purpose of this analysis was to determine the control rate after radiation, identify any prognostic factors and evaluate the late toxicity. MATERIALS AND METHODS: From 1972 to 1986, 145 patients received RT for hormonally-active pituitary adenomas. The median age was 39 years (range 15-76), with 81 males and 64 females. There were 52 patients with acromegaly, 64 with prolactinoma, and 29 with Cushing's disease. The median follow-up was 7.3 years. RT was given as primary treatment in 17 patients, after initial surgery in 65 patients, and as part of salvage therapy in 63 patients. The median total dose was 50 Gy (daily fraction: 2 Gy). Tumor control was defined as normalization of basal hormonal level and lack of progression of adenoma assessed by imaging studies. The following factors were analyzed for prognostic significance in tumor control: age, sex, tumor type, direction of tumor extension, radiation dose, and radiation field size. RESULTS: The 10-year actuarial proportion of patients with persistent elevated hormone level were 61% following RT alone, and 44% with the addition of medical management. The progression-free rate was 96% at 10 years. Of the 20 deaths, three patients died with uncontrolled pituitary adenoma and three died of treatment complications. The actuarial 10-year overall and cause-specific survival rates were 86% and 97%. The actuarial rates of radiation-induced hypopituitarism were 35%, 22% and 22% at 10 years for thyroid, glucocorticoid and gonadal functions, respectively. None of the factors examined were found to be significant predictors of tumor control. CONCLUSIONS: Post-operative external beam RT is highly effective in preventing recurrence of space-occupying effects of hormonally-active pituitary adenomas. However, long-term biochemical remission is observed only in approximately 40% of patients (at 10 years), with an additional 20% requiring medical therapy. Malignancies of the CNS can develop as an infrequent late event.

Acromegaly↗

PubMed1996

Medullary thyroid cancer: analyses of survival and prognostic factors and the role of radiation therapy in local control.

Records of 73 patients with medullary thyroid cancer were reviewed to assess prognostic factors and the role of external beam radiation therapy. Patients were treated between 1954 and 1992. The median age was 49 years (range 15-85), M:F ratio 1.6:1, and the median follow-up was 7.9 years. (2.5-34.6). The primary tumor size was < 1 cm in 10%, 1-4 cm in 53%, and > 4 cm in 37%. Multifocality was noted in 32%, and 23% had metastasis at presentation. Eight patients presented with inoperable tumors, 40% had gross, and 37% microscopic residual disease postthyroidectomy. Extraglandular extension was present in 56%, and 74% had pathologically involved lymph nodes. Treatment was by total or near total thyroidectomy in 41 patients; 37 had a lymph node dissection. Forty-six patients were irradiated, the dose of radiation ranging from 20 to 75.5 Gy; median was 40 Gy, treatment time median was 28 days and the median number of fractions was 20. The overall cause specific survival (CSS) was 70% and 57% at 5 and 10 years, respectively. In a univariate analysis, the following factors predicted for lower CSS: age as a continuous variable (p = 0.003), male gender (p = 0.008), presence of distant metastasis (p < 0.0001), lymph node involvement (p = 0.03), gross residual disease (p < 0.0001), tumor size > 4 cm (p = 0.05), extraglandular invasion (p < 0.004), vascular invasion (p = 0.007), diarrhea (p < .0007), and abnormal postoperative calcitonin (p = 0.02). On multivariate analysis only two factors were significant: the presence of extraglandular invasion, and postoperative gross residual disease. There was no difference in local/regional relapse free rate between patients receiving external radiation and those that did not, but in 40 high risk patients (microscopic residual disease, extraglandular invasion, or lymph node involvement), the local/regional relapse free rate was 86% at 10 years with postoperative external beam radiation (25 patients), and 52% for those with no postoperative external radiation (p = 0.049). To optimize local/regional tumor control, we therefore continue to advise external beam radiation in patients at high risk of local/regional relapse.

Adolescent↗

PubMed1996

Squamous cell carcinoma of the breast.

OBJECTIVE: To review the mammographic and ultrasonographic features of primary breast cancer containing squamous cell carcinoma. PATIENTS AND METHODS: From medical records for breast cancer patients seen over a 37-year period the authors identified 19 patients with squamous cell carcinoma, for 5 of whom histologic sections and imaging studies were available. The tumours were classified on the basis of histologic findings as pure (in two patients) or predominantly (in three patients) squamous cell carcinoma. Mammograms were available for four of the patients, and the mammographic report only was available for analysis for the fifth. Ultrasonography had been performed for four of the patients; the images were available for two of the patients and the reports only for two. RESULTS: The median age of the patients was 55 years. The mean size of the tumours, all of which were palpable, was 5.0 cm. None of the tumours was connected to the skin, arose in the nipple-areolar complex or was metastatic. On mammography, the margins of all five masses, which were oval in shape, were indistinct and partly well-circumscribed; in three cases, the tumour margin was also partly spiculated. No malignant microcalcifications were seen. The two "pure" squamous cell carcinoma tumours appeared on ultrasonography as solid hypoechoic masses, and two of the predominantly squamous cell carcinoma tumours had both cystic and solid components. At gross pathological examination, four of the tumours (two "pure" and two predominantly squamous cell carcinoma) were cystic, which reflected areas of necrosis and cyst formation. CONCLUSION: Although "pure" or predominantly squamous cell carcinoma is a rare histologic variant of breast cancer that lacks any typical mammographic features, this tumour can be added to the differential diagnosis of cystic breast masses seen on ultrasonography.

Aged↗

PubMed1995

Aggressive fibromatosis: optimisation of local management with a retrospective failure analysis.

The records of 40 consecutive patients treated at the Princess Margaret Hospital (PMH) between 1979 and 1988 for aggressive fibromatosis were reviewed. The median follow-up was 86 months (range 21-167 months). All surgery was performed at the referring hospitals. Thirty-six underwent an attempt at excision, four were biopsied. Thirty-one had no overt disease after surgery and 26 of these received adjuvant irradiation. Eight were treated with radiotherapy alone, and another was treated with azathioprine and prednisone. Twenty-four (60%) presented with recurrent disease. The overall relapse free rate was 63% at 5 and 10 years. Combined surgery and irradiation had a higher relapse rate than irradiation alone (46% vs. 25%), and a high proportion of failures in the combined group were marginal failures (36%). Relapses following surgery alone were 1/5 (20%), and chemotherapy 0/1. Tumour size greater than 8 cm predicted for relapse (p = 0.002), but tumour site, status of surgical margins, and presence or absence of a history of relapse were not statistically significant. Twelve with subsequent treatment failure underwent successful salvage surgery, and 37/40 (92%) were disease free at last follow-up. A functional assessment (modified Johnstone scale) revealed 11/24 patients (46%) with poor functional outcomes (grade 2 or less) after all treatment compared with 6/24 (25%) at referral. Ten of 11 (91%) with grade of 2 or less had a history of recurrence, and 4/5 amputations were for treatment of a painful recurrence. Treatment planning in this study was hampered by inadequate information on tumour location since few patients had clinically apparent disease when seen by the radiation oncologist (only 35% of cases) and fewer had preoperative cross-sectional imaging available (12% of cases).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1995

Clinico-pathological predictors of recurrence for acinic cell carcinoma.

The biological behaviour of acinic cell carcinomas, even if well differentiated, is unpredictable. We studied 45 patients with acinic cell carcinoma followed-up from 10 to 379 months (5 year recurrence-free and survival rate of 69% and 81% respectively), and compared clinico-pathological parameters with outcome. The presence of a predominately solid architecture was strongly associated with a poor outcome (P < 0.01) and this was the only independent prognostic variable when log rank testing was performed. Tumour size (> 2.75 cm) was a significant predictor of recurrent deep parotid lobe involvement, the presence of cervical nodal disease and lymphocytic infiltration, although not significant, factors showed a tendency towards recurrence. For acinic cell carcinoma, the predominant solid architecture would appear to be a strong predictor of recurrence.

Adolescent↗

PubMed1995

Stage I testicular seminoma: results of adjuvant irradiation and surveillance.

PURPOSE: To assess the results of treatment and patterns of relapse in a contemporary group of patients with stage I testicular seminoma managed by adjuvant radiation therapy (RT) and surveillance. PATIENTS AND METHODS: Between January 1981 and December 1991, 364 patients with stage I seminoma were treated at Princess Margaret Hospital. Of these, 194 were treated with adjuvant RT (92% received a dose of 25 Gy in 20 fractions for 4 weeks) and 172 were managed by surveillance. Two patients were included in this series twice--both had postorchiectomy RT for stage I disease, developed a contralateral seminoma, and were placed on surveillance and analyzed for outcome of both primary tumors. The median follow-up period for patients treated with adjuvant RT was 8.1 years (range, 0.2 to 12), and for patients managed by surveillance, it was 4.2 years (range, 0.6 to 10.1). RESULTS: The overall 5-year actuarial survival rate for all patients was 97%, and the cause-specific survival rate was 99.7%. Only one patient died of seminoma. Of 194 patients treated with RT, 11 have relapsed, with a 5-year relapse-free rate of 94.5%. Prognostic factors for relapse included histology, tunica invasion, spermatic cord involvement, and epididymal involvement. Twenty-seven patients developed disease progression on surveillance, which resulted in a 5-year progression-free rate of 81.9%. The only factor identified to predict progression on surveillance was age at diagnosis: patients aged < or = 34 years had a 26% risk of progression at 5 years, in contrast to a 10% risk of progression in those greater than 34 years of age. CONCLUSION: The outcome of patients with stage I testicular seminoma is excellent, with only one of 364 patients (0.27%) dying of disease. In our experience, both a policy of adjuvant RT and of surveillance resulted in a high probability of cure. Our surveillance experience showed that four of five patients with stage I seminoma are cured with orchiectomy alone. The benefit of adjuvant RT was reflected in a decreased relapse rate. We have identified a number of prognostic factors for relapse in patients managed with both approaches, but further study of prognostic factors is required, particularly to identify patients at high risk of disease progression on surveillance.

Actuarial Analysis↗