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ABSTRACT: We aimed to assess outcomes of patients with anal cancer who underwent intensity-modulated radiotherapy (IMRT) and received less than 1.80 Gy/day.
We retrospectively reviewed our experience using a low fractional dose (< 1.80 Gy) of IMRT to elective nodal areas for patients receiving chemoradiotherapy for anal cancer. Three-year freedom from any disease relapse and overall survival were estimated using Kaplan-Meier curves. We documented the daily dose that was delivered to clinically uninvolved regions and to areas of gross disease. Incidence of regional failures in high (≥ 1.80 Gy) and low (< 1.80 Gy) daily dose regions was assessed.
Thirty-four consecutive patients (median age, 59 years) received IMRT from June 2005 through January 2009. Median follow-up duration was 22 months. Twenty-eight patients had T1 or T2 disease and 6 had T3 or T4 disease. Fourteen patients had nodal metastases. Median treatment dose was 50.40 Gy (range, 48.60-57.60 Gy) in 25 to 32 fractions. The range of fractional doses to clinically negative volumes was 1.28 to 1.80 Gy. Seventeen patients (50%) received a fractional dose of less than 1.60 Gy, 13 (38%) received less than 1.50 Gy, and 9 (26%) received less than 1.40 Gy to at least a portion of the clinically negative volume. Three-year freedom from relapse was 80%, and 3-year overall survival was 87%. No patient had treatment failure in the clinically negative volume that received a low daily dose.
Our data support using doses between 1.50 and 1.80 Gy/day to clinically uninvolved regions.
Radiation Oncology 01/2011; 6:134. · 2.32 Impact Factor
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ABSTRACT: To identify and describe clinicopathologic prognostic factors in patients with esophageal adenocarcinoma who underwent surgical resection with curative intent.
The study cohort consisted of 796 patients with adenocarcinoma of the esophagus, gastroesophageal junction, or gastric cardia who underwent complete tumor resection at Mayo Clinic from January 1, 1980, to December 31, 1997. We reviewed individual patient medical records and abstracted demographic, pathologic, perioperative, and cancer outcome data. Median follow-up for vital status and disease recurrence was 12.8 and 5.8 years, respectively.
Univariate analysis revealed the following factors to be statistically associated with worse 5-year disease-specific survival: higher N and T status, higher tumor grade, age older than 76 years, and the presence of extracapsular lymph node extension and signet ring cells. The following factors remained significantly linked with worse 5-year disease-specific survival on multivariate analysis: higher N and T status, grade, and age and the absence of preoperative chemotherapy or radiotherapy. Anatomic location of tumor was not associated with differential prognosis. Lymph node metastases were found in 25 (27%) of 93 T1b tumors, 397 (85%) of 468 T3 tumors, and 22 (67%) of 33 T4a tumors. Disease-specific survival was better in T3-4N0 than in T1bN1-3 carcinomas (hazard ratio, 0.50; 95% confidence interval, 0.28-0.89, adjusted for grade and age; P=.02).
Our results confirm the importance of T and N status and tumor grade and suggest that age may affect prognosis. In addition, we show that a significant proportion of superficial esophageal adenocarcinomas exhibit regional metastases and have worse prognosis than more invasive nonmetastatic tumors.
Mayo Clinic Proceedings 12/2010; 85(12):1080-9. · 5.70 Impact Factor
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ABSTRACT: The purpose of this article is to review pertinent literature assessing the evidence regarding adjuvant chemoradiotherapy for adenocarcinoma of the pancreas following curative resection. This review looks at randomized controlled studies with the emphasis on adjuvant chemoradiotherapy. In assessing the evidence from the studies reviewed in this article, the trials have been grouped according to the positive or negative results for or against adjuvant treatment. In addition, data from two large, single-institution studies affirming the role for adjuvant chemoradiotherapy has been included. Understanding the evidence from all of the randomized studies is important in shaping current practice recommendations for adjuvant therapy of surgically resected pancreas cancer. Adjuvant chemoradiotherapy following surgery is the current approach at many cancer treatment centers in the United States. In Europe, chemotherapy alone is the preferred adjuvant therapy. However, the type of adjuvant treatment recommended remains controversial due to conflicting study results. The debate will likely continue. Current practice should be based on the weight of evidence available at this time, which is in favor of adjuvant chemotherapy with chemoradiotherapy.
World journal of gastrointestinal surgery. 11/2010; 2(11):373-80.
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ABSTRACT: The optimal treatment of small bowel adenocarcinoma is unknown.
The records of 491 patients with small bowel adenocarcinoma diagnosis between 1970 and 2005 were reviewed for patient and tumor characteristics, treatment effects, and survival.
The median age at diagnosis was 62 years. The most common tumor locations were the duodenum (57%), jejunum (29%), and ileum (10%). The median overall survival was 20.1 months, with a 5-year overall survival of 26%. Greater age, male sex, higher stage and grade, residual disease after resection, and a lymph node ratio of 50% or greater predicted decreased overall survival in univariate analysis. Age and stage were predictive of survival in multivariate analysis. The overall survival with metastatic disease was poor. Adjuvant therapy was not associated with longer overall survival (P = .44).
The prognosis of patients with small bowel adenocarcinoma is poor. Complete resection provides the only means of cure, and the role for adjuvant therapy remains uncertain.
American journal of surgery 06/2010; 199(6):797-803. · 2.36 Impact Factor
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Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 02/2010; 5(2):284; author reply 284-5. · 4.55 Impact Factor
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ABSTRACT: The management of esophageal cancer with involvement of celiac lymph nodes is controversial. The purpose of this retrospective study was to evaluate the clinical importance of metastases to celiac lymph nodes in patients with carcinoma of the distal esophagus or gastroesophageal junction (GEJ) who undergo surgical treatment with curative intent. We reviewed the medical records of 310 patients who underwent definitive esophagectomy at the Mayo Clinic, Rochester, Minnesota, between 1976 and 1999 for carcinoma of the distal esophagus or GEJ. The disease location was distal esophagus in 163 and GEJ in 147. Fifty-two patients (17%) were found to have celiac node involvement. The survival of these patients was compared with that of 97 N0 patients and 161 N1 patients without celiac node involvement. Squamous cell carcinoma and adenocarcinomas were found in 24% and 76%, respectively. Ivor Lewis esophagectomy was the most common surgical procedure (76%), followed by transhiatal resection (14%) and modified Ivor Lewis procedure (5%). The median number of nodes resected was 15 (range, 2-45). The median survival of the entire group was 18.8 months. The median survival was 48 months (range, 1.6 months-22 years) for N0 patients and 15.9 months (range, 0.03 months-14.4 years) for N1 patients without celiac node disease (P < 0.001). The median survival was 11.7 months (range, 2.2 months-15.7 years) for celiac node-positive patients, and this difference was statistically significant when compared with survival in N0 patients (P= 0.001) but not when compared with that in N1 patients without celiac node disease (P= 0.57). Survival at 3 and 5 years was 61% and 45% for N0 patients, 21% and 9% for N1 patients without celiac node disease, and 18% and 11% for patients with celiac node disease, respectively. At 10 years, 7% of patients with celiac node involvement in their resected specimen were alive. By multivariate analysis, patients with 4 or more positive lymph nodes had the worst prognosis (risk ratio [RR], 2.63; 95% confidence interval [CI], 1.98-3.48), regardless of their location. We concluded that celiac node metastases were not an adverse prognostic indicator in patients with celiac node involvement compared with N1 patients without celiac node disease. Overall, the number of positive nodes, not their location, correlated best with survival. Although median survival was poor, a small number of patients with resected celiac node disease had long-term survival. Patients with undetected celiac node disease at the time of surgical resection who were subsequently found to have celiac node involvement appeared to have a prognosis similar to that of patients with stage III disease. Therefore, treatment with curative intent should be considered for fit patients with celiac node disease.
Diseases of the Esophagus 06/2009; 23(3):232-9. · 1.81 Impact Factor
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ABSTRACT: To determine prognostic factors and the impact of intraperitoneal (IP) treatment after surgical resection of peritoneal mucinous carcinomatosis (PMC) of appendiceal origin.
PMC is a rare, malignant, intra-abdominal neoplasm that produces large amounts of mucin. Patients typically present with diffuse peritoneal disease. After surgical treatment, multiple locoregional recurrences are common; recurrences outside the abdomen are infrequent. Treatment regimens include debulking, radiotherapy with IP radioisotopes, and chemotherapies (IP, systemic, or both). Because reported data are variable and heterogeneous, treatment evaluations are challenging.
We retrospectively reviewed 115 consecutive patients with PMC who underwent maximal surgical resection with or without postoperative therapy between 1985 and 2000 at Mayo Clinic Rochester. After maximal resection, 37 patients received IP 5-fluorouracil, 35 of whom also received IP chromic phosphate P 32. The Kaplan-Meier method was used to estimate overall survival (OS) and disease-free survival.
All gross disease was removed in 61% of patients. With a median follow-up of 6.1 years, the median OS was 8.1 years. Median OS for patients receiving versus not receiving IP therapy was 23.5 years versus 7.5 years, respectively. The 5-, 10-, and 15-year OS for those receiving and not receiving IP therapy was 82%, 65%, and 52% versus 60%, 27%, and 15%, respectively. Adverse prognostic factors for OS identified by univariate analysis included partial mucin debulking, adenocarcinoma histology, systemic chemotherapy, diffuse IP disease at presentation, and no IP therapy. On multivariate analysis, diffuse IP disease at presentation and no IP therapy remained significant. A separate analysis was performed for the 70 patients who underwent gross total resection, 51% of whom received IP therapy. Adverse prognostic factors for OS included adenocarcinoma histology, systemic chemotherapy, and no IP therapy.
This large, single-institution, retrospective series with long-term follow-up suggests that IP chromic phosphate P 32 and 5-fluorouracil after maximal surgical resection of PMC of appendiceal origin is associated with improved OS and disease-free survival.
Annals of surgery 05/2009; 249(4):588-95. · 7.90 Impact Factor
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ABSTRACT: Outcome results of a long-term analysis of urachal cancer using a new staging system are presented.
The authors analyzed clinical outcomes from 49 patients with the diagnosis of urachal cancer who were seen at the Mayo Clinic, Rochester, Minnesota from 1950 to 2003. The TNM staging system was used to predict outcome after surgical resection.
Among 49 study patients, 33 were men, 16 were women, and their median age at presentation was 57.5 years. The vast majority of tumors were adenocarcinomas (89%), 4% were sarcomas and transitional cell carcinomas, and the rest were high-grade mixed neoplasms. Among the adenocarcinomas, 63.6% were mucin-producing tumors. Partial cystectomy with or without pelvic lymph node dissection and removal of the urachus was performed in 41 (83%) cases. Overall survival for all stages was 62 months with 17 (34%) patients still alive more than 5 years after treatment. Applying the TNM staging system, the authors demonstrated a median survival time for stage I/II patients of 10.8 years (95% CI, 6.9 years to 12.0 years) compared with a median survival of 1.3 years (95% CI, 1.1 years to 1.9 years; log-rank P<.0001) for patients with advanced disease (stages III and IV).
Stage at presentation by the TNM staging system proved to be the main predictor of outcome after surgery for urachal cancer. Better systemic modality treatments are needed for advanced stages of this disease.
Cancer 12/2007; 110(11):2434-40. · 4.77 Impact Factor
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ABSTRACT: Small cell carcinoma (SCC) of the urinary bladder accounts for 0.35-0.70% of all bladder tumors. There is no standard approach to the management of SCC of the urinary bladder.
The authors performed a retrospective study at Mayo Clinic (Rochester, MN) to characterize the clinical and pathologic features of patients with SCC of the urinary bladder diagnosed between 1975 and 2003 with emphasis on management.
Forty-four patients were identified who had primary bladder SCC, 61.4% of whom had pure SCC. The male:female ratio was 3:1, the mean age was 66.9 years, and the mean follow-up was 3.2 years. Twelve patients (27.3%) had Stage II disease, 13 patients (29.6%) had Stage III disease, and 19 patients (43.2%) had Stage IV disease. The overall median survival was 1.7 years. The 5-year survival rates for patients with Stage II, III, and IV disease were 63.6%, 15.4%, and 10.5%, respectively. Six of eight patients with Stage II bladder SCC achieved a cure with radical cystectomy. Five patients with Stage IV disease had obvious metastases and received chemotherapy. Fourteen patients underwent radical cystectomy and were diagnosed later with locally advanced disease (T4b) or lymph node metastasis (N1-N3; Stage IV disease). Only 2 of 19 patients with Stage IV disease who received adjuvant chemotherapy were alive at 5 years.
Patients with bladder SCC should undergo radical cystectomy except when metastatic disease is present (M1), in which case, systemic chemotherapy is indicated. Adjuvant treatment is not indicated for patients with Stage II disease after radical cystectomy but should be considered for patients with Stage III and IV disease. Chemotherapy should be a platinum-based regimen.
Cancer 04/2005; 103(6):1172-8. · 4.77 Impact Factor
