Gliomatosis cerebri. Results with radiation therapy.

BACKGROUND: This review was undertaken to determine the outcome for patients diagnosed in the modern era and treated with radiation therapy. METHODS: Using the tumor registries of six institutions in a large metropolitan area, cases of gliomatosis were identified and retrospectively reviewed. RESULTS: The clinical course for each patient was unique. Deterioration during treatment, brief stabilization, and reversal of the clinical signs and symptoms with stability and high quality of life at 16 months from diagnosis characterized Patients 1, 2, and 3, respectively. CONCLUSIONS: Radiotherapy for gliomatosis appears to stabilize or improve neurologic function in some patients. Its impact on survival will await additional reports and longer follow-up.

Transitional cell carcinoma of the renal pelvis or ureter: patterns of failure.

OBJECTIVES: To identify recurrence patterns and possible indications for adjuvant treatment. METHODS: Ninety-four patients with transitional cell carcinoma of the renal pelvis or ureter were reviewed to determine their pattern of failure. Factors including gender and age, tumor stage and grade, and extent of surgical procedure and adjuvant radiation therapy (RT) were analyzed with respect to local and distant recurrence and survival. RESULTS: Seventy-seven patients had resections without residual. On multivariate analysis, grade (P = 0.01) and adjuvant RT (P = 0.02) had significant effects on local control. Metastases were solely dependent on stage (P = 0.0001). Survival was dependent on stage (P = 0.0059) and age (P = 0.036), with the use of adjuvant RT of borderline significance (P = 0.07). Twenty-seven patients were excluded from local failure and survival analysis; of these, 3 died within 1 month of surgery, 5 had metastasis at presentation, and 19 had local disease that was unresectable. Eleven of these 19 were treated by RT, resulting in 2 long-term disease-free survivors after receiving doses of 45 and 50.4 Gy. CONCLUSIONS: In patients with adverse factors, such as high grade or stage, close margins, or positive nodes, local control can be improved with adjuvant radiation. Improvement in survival is of borderline significance on multivariate analysis, with approximately 50% of high stage or grade patients developing metastasis.

Role of postoperative radiation therapy after stabilization of fractures caused by metastatic disease.

PURPOSE: Although orthopedic stabilization is frequently performed for pathological fractures caused by metastatic disease, no data is available to support the value of postoperative radiation therapy (S+RT) in this setting. METHODS AND MATERIALS: We reviewed 64 orthopedic stabilization procedures in 60 consecutive patients with metastatic disease to previously unirradiated weight-bearing bones with pathological or impending pathological fracture (femur 91%). Thirty-five sites that received adjuvant S+RT were compared to 29 sites that were treated with surgery alone (SA). Many potential prognostic variables were evaluated. Endpoints were: functional status (FS) of the extremity (1 = normal pain free use; 2 = normal use with pain, 3 = significantly limited use; 4 = nonfunctional extremity), subsequent orthopedic procedures to the same site, and survival following surgery. RESULTS: At the univariate level, S+RT (p = 0.02) and prefracture FS (p = 0.04) were the only significant predictors of patients achieving an FS of 1 or 2 after surgery. On multivariate analysis, only postoperative RT was significantly (p = 0.02) associated with attaining FS of 1 or 2 after surgery. The predicted probability of achieving FS 1 or 2 at any time was 53% for S+RT vs. 11.5% or SA (multiple logistic regression, p < 0.01). Evaluation of FS following surgery revealed that S+RT group had significantly better function in the 1-3, 3-6, and 6-12 month postoperative periods (chi-square, p < 0.04 for each time period). Second orthopedic procedures to the same site were more common in the SA group than the S+RT group (log rank, p = 0.03). Actuarial median survival of S group was 3.3 months compared with 12.4 months for the S+RT group (log rank, p = 0.02), confirming the beneficial association with survival shown by the multivariate Cox regression analysis (p = 0.025). CONCLUSION: Although this retrospective study is subject to possible biases, several analyses adjusting for numerous prognostic factors uniformly indicate S+RT is the most important factor in patients achieving and maintaining normal functional status (+/- pain). Further, the S+RT group was associated with fewer orthopedic procedures as well as an improved overall survival. The improved survival may be due to (a) more favorable patients being referred for RT (possible section bias), or (b) improved functional status in the S+RT group. This study quantitatively supports the benefit of postoperative RT in this setting.

Impact of postoperative radiation therapy and other perioperative factors on outcome after orthopedic stabilization of impending or pathologic fractures due to metastatic disease.

PURPOSE AND METHODS: We reviewed 64 orthopedic stabilization procedures in 60 consecutive patients diagnosed with metastatic disease to previously unirradiated femurs, acetabula, and humeri with pathologic or impending pathologic fracture. Thirty-five patients who received adjuvant postoperative radiation therapy were compared with 29 patients who were treated with surgery alone. Many potential perioperative and tumor prognostic variables were evaluated. RESULTS: On univariate analysis, surgery plus radiation therapy and prefracture functional status were the only significant predictors of patients who achieved normal use of the extremity (with or without pain) after surgery; on Cox multivariate analysis, only postoperative radiation therapy was significant (P = .02). Surgery-related factors such as use of methylmethacrylate, location of fracture, and type of surgery were not associated with improved functional status. The estimated probability of achieving normal use of the extremity (with or without pain) any time was 53% for postoperative radiation therapy versus 11.5% for surgery alone (P < .01). Second orthopedic procedures to the same site were more frequent in the group that received surgery alone. The actuarial median survival duration of the surgery-alone group was 3.3 months, compared with 12.4 months for the postoperative radiation therapy group (P = .02). CONCLUSION: While this study is limited by possible unaccountable selection biases, only postoperative radiation therapy was associated with patients regaining normal use of their extremity (with or without pain) and undergoing fewer reoperations to the same site. The improved overall survival associated with postoperative radiation therapy may represent selection bias.

Adjuvant radiotherapy in high stage transitional cell carcinoma of the renal pelvis and ureter.

This review was undertaken to assess the influence of adjuvant radiation therapy on failure patterns and survival in high stage transitional cell carcinoma of the renal pelvis or ureter. Ninety-four patients with transitional cell carcinoma of the renal pelvis or ureter were retrospectively reviewed. Twenty-six had American Joint Commission stage T3 or T4 N0/+, M0 disease and underwent curative resections (median follow-up 13.5 months, range 3-311). Local failure was defined as recurrence in the tumor bed, regional nodes, or ureteral stump. Time to recurrence and survival were calculated from the time of pathologic diagnosis. Variables associated with local failure, distant metastasis, and survival were analyzed using univariate and multivariate analysis. Seventeen received surgery only, nine received adjuvant radiation therapy (median dose 50 Gy). Local failure occurred in 9 of 17 without and 1 of 9 with adjuvant radiation therapy (p = 0.07). Actuarial 5-year local control was 34% without and 88% with adjuvant radiation therapy. Cox step-wise regression confirmed adjuvant radiation therapy (p = 0.006) and grade (p = 0.006) as significantly associated with local failure. No patients with low grade lesions suffered local failure either with or without adjuvant radiation therapy. High grade lesions had an local failure rate of 15% with and 71% without adjuvant radiation therapy. Metastatic disease occurred in 4 of 9 and 8 of 17 with and without radiation therapy. No significant factors influencing distant failure were identified. Five-year actuarial survival was 44% with and 24% without adjuvant radiation therapy. The survival differences were not statistically significant on univariate or multivariate analysis. High staged transitional cell carcinoma of the renal pelvis or ureter has a substantial local failure risk after surgery alone. Adjuvant radiation therapy markedly reduces this risk but has no impact on distant disease which occurs in approximately 50%. Effective adjuvant therapy will require effective systemic therapy in addition to adjuvant radiation therapy.