Locoregional first recurrence after mastectomy: prospective cohort studies with and without immediate chemotherapy.

PURPOSE: To evaluate prospectively the impact of combination chemotherapy in the combined modality treatment of isolated first locoregional recurrence (LRR) following mastectomy for breast cancer. METHODS AND MATERIALS: Between 1979 and 1989, 120 chemotherapy-naive women with isolated LRR as first failure after mastectomy were prospectively identified, uniformly staged, and systematically followed. Treatment consisted of excision if feasible, radical locoregional radiotherapy, and a hormonal maneuver (unless estrogen receptor negative). The initial chemotherapy cohort also received 8 cycles of doxorubicin and cyclophosphamide. This was compared to a subsequent control cohort. RESULTS: For all patients, the 10-year actuarial relapse-free survival +/- 95% confidence interval was 42.1+/-9.2%, and overall survival was 56.8+/-9.1%. No difference was seen in locoregional control between cohorts. At 5 years, distant recurrence-free survival for chemotherapy and control cohort respectively was 75.4+/-10.8% and 60.7+/-12.5% (p = 0.33) and overall survival was 81.9%+/-9.6 and 74.3%+/-11.2 (p = 0.24). Univariate analysis showed no prognostic importance for any imbalance between cohorts. Cox modeling confirmed that complete resection was strongly associated with fewer LRR (hazard ratio [HR] 0.32, p = 0.001) and also with better overall survival (HR 1.82, p = 0.019). Chemotherapy produced a substantial reduction in risk of death (HR 0.72 CI 0.421-1.235, p = 0.23). CONCLUSIONS: In this prospective but nonrandomized study of treatment for first LRR, the risk of death in the later control cohort was 1.39 times the risk in the chemotherapy cohort but failed to reach statistical significance. The results justify further study.

Primary radiotherapy for subglottic carcinoma.

Between 1976 and 1990, 23 patients with subglottic carcinoma of the larynx were treated by one radiotherapist; these were reviewed. Primary radiotherapy was given using small parallel opposed wedged fields to the neck. No mediastinal radiotherapy was used. Mean follow up was 67 (9-165) months. Actuarial analysis showed a 2-year overall survival of 69.0% (78.3% excluding intercurrent deaths), and a 2-year disease free survival of 68.6%. Failure was due to persistent disease (5 patients) or recurrence (2 patients, both with disease T3, salvaged by surgery at 5 and 20 months). No patient developed clinical mediastinal relapse. These better than expected results support the use of primary radiotherapy to the neck alone avoiding conventional mediastinal radiotherapy. A national questionnaire sent to 67 consultant otolaryngologists sought information on perceived incidence, cure rate, and preferred mode of treatment and produced a 67% response rate. The results confirmed our belief that surgeons have a pessimistic perception of the value of radiotherapy in this condition.

Stage I endometrial carcinoma: the role of neoadjuvant progesterone therapy.

A prospective study was devised in 1980 to assess the effect on survival of neoadjuvant Provera as part of the primary treatment of endometrial carcinoma in conjunction with surgery and radiotherapy. Between June 1980 and June 1985, 218 patients with Stage I adenocarcinoma of the corpus uteri were allocated on the basis of hospital of presentation to receive either neoadjuvant treatment with medroxyprogesterone acetate (MPA) 100 mg t.i.d. p.o. from diagnosis for 90 days, or no adjuvant treatment (the control group). The minimum follow-up was 5 years. There was no significant difference between the overall actuarial survival in the treatment group (123 cases) and that in the control group (95 cases). This was 83.7% and 69.2% at 5 and 10 years respectively in the treatment group and 78.9% and 70.7% in the control group (P > 0.1).

The treatment of squamous cell carcinoma of the paranasal sinuses.

Of 72 cases of paranasal sinus malignancy that were identified, 47 were biopsy proven squamous cell carcinomas. Actuarial analysis of these patients receiving both radical and palliative treatment revealed an overall 5-year survival of 37.4%, and a relapse-free survival of 31.6%. For patients receiving radical treatments (i.e. radiotherapy alone, or preoperative radiotherapy followed by elective surgery), the 5-year survival results were identical (46%). In this series radiotherapy alone is an effective treatment, and subsequent planned surgery did not improve the survival.