Faculty Bibliography

OBJECTIVE: The optimal management of stage II endometrial cancer remains uncertain. We examined the role of radical hysterectomy and adjuvant radiotherapy for stage II endometrial cancer. STUDY DESIGN: The Surveillance, Epidemiology, and End Results database was used to identify 1577 women with stage II endometrioid type endometrial adenocarcinoma who underwent surgical staging. RESULTS: The cohort included 1198 women who underwent simple hysterectomy (76%) and 379 who underwent radical hysterectomy (24%). Radical hysterectomy had no effect on survival (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.61-1.23). Patients who did not receive radiation were 48% (HR, 1.48; 95% CI, 1.14-1.93) more likely to die than those who underwent adjuvant radiotherapy. The survival benefit from radiation was most pronounced in women who underwent radical hysterectomy. CONCLUSION: Adjuvant radiation improves survival. Although the routine performance of radical hysterectomy does not appear to be justified, patients with high-risk stage II tumors appear to benefit from combination therapy with radical hysterectomy and radiotherapy

Purpose: Several studies have reported computerized tomography (CT) overestimates prostate volume by 30 to 50% in comparison to ultrasound in prostate radiation therapy. To further elucidate this phenomenon, we compared the differences in prostate volume assessed by ultrasound and CT, specifically with in vivo and ex vivo ultrasound, and ex vivo CT. Method and Materials: Seven patients with localized prostate cancer treated with radical prostatectomy were enrolled. Each patient was scanned with transrectal ultrasound (TRUS) prior to surgery. Prostate specimens were immediately scanned post‐surgery with both ultrasound and CT. 3‐D imaging scans were acquired from the base to the apex of the prostate in the axial plane in 2 mm and 1.25 mm slices for ultrasound and CT imaging, respectively. The prostate gland was contoured on each 3‐D ultrasound and CT image set by one radiation oncologist and then volume calculations were made based on voxel size. Results: The in vivo prostate volume acquired with ultrasound was on average 33.2 cc (range 25.7 – 41.3 cc). The ex vivo CT and ultrasound volumes of the prostate specimens were 32.8 cc (range 24.7 – 41.1) and 32.7 cc (range 24.9 – 40.3), respectively. The ex vivo and ex vivo ultrasound prostate volume measurements were within 5% of each other. Overall, there was a 1 to 2% reduction between the imaged pre and post‐surgery prostate volumes. For each individual specimen the concordance between the CT and ultrasound volumes was within 5%. Conclusion: While several studies have consistently reported larger prostate volumes when using CT as compared to transrectal ultrasound, our study shows no intrinsic difference between ultrasound and CT imaging in terms of prostate volume measurements. Therefore, we propose the difficulty with precise prostate contour delineation encountered with CT imaging results in the frequent overestimation of the prostate gland size seen in prostate radiation therapy

BACKGROUND: Fallopian tube cancers are rare neoplasms. These malignancies are thought to behave biologically and clinically like ovarian cancer. The purpose of this study was to compare the clinical behavior and outcome of fallopian tube and ovarian cancer. METHODS: The Surveillance, Epidemiology, and End Results database was reviewed to identify women with tumors of the fallopian tube (FT) and ovary (OV) diagnosed between 1988 and 2004. Demographic and clinical data were compared, and the impact of tumor site on survival was analyzed using Cox models and the Kaplan-Meier method. RESULTS: A total of 55,825 patients were identified, 1576 (3%) with FT and 54,249 (97%) with OV cancer. FT patients were more likely to present with early stage tumors (P < .001). Among FT patients, 47% had stage I/II tumors compared with 29% of OV cancers. In an adjusted Cox model of all patients, cancer-specific mortality was 48% lower in FT patients (hazard ratio, 0.52; 95% confidence interval [CI], 0.48-0.56) compared with OV cancer. Among patients with FT tumors, advanced age and stage were independent predictors of decreased survival. When stratified by stage, survival was similar for stage I and II tumors, but stage III and IV FT patients had an improved survival. The 5-year survival for stage III FT cancer was 54% (95% CI, 48%-60%), compared with 30% (95% CI, 29%-31%) for OV. CONCLUSIONS: Fallopian tube cancers present earlier and at advanced stage have a better overall survival than primary ovarian malignancies. Future clinical trials should recognize the possible distinct clinical behavior of fallopian tube cancers

OBJECTIVE: To compare the clinical behavior and outcome of uterine carcinosarcomas and grade 3 endometrioid carcinomas. METHODS: Data on patients with grade 3 endometrioid adenocarcinomas and uterine carcinosarcomas, from 1988 to 2004, was obtained from the Surveillance, Epidemiology, and End Results database. Mortality was analyzed using Cox proportional hazards models. Survival analysis was performed with the Kaplan-Meier method and log rank test. RESULTS: The cohort included 8,986 women with 5,024 (56%) grade 3 endometrioid carcinomas and 3,962 (44%) uterine carcinosarcomas. Women with uterine carcinosarcomas were older (aged 70 years compared with 66 years; P<.001) and more often nonwhite (23% compared with 15%; P<.001). These women presented with more advanced disease (stage III/IV 41% compared with 31%; P<.001). Multivariable analysis demonstrated that uterine carcinosarcoma histology, advanced age, nonwhite race, and advanced stage were independent predictors of poor survival. Cancer-specific mortality was 45% lower in women with grade 3 endometrioid carcinomas (hazard ratio 0.55; 95% confidence interval [CI] 0.5-0.6). The 5-year cancer-specific survival was lower for women with uterine carcinosarcoma for each disease stage. Survival for stage IC was 38% (95% CI 33-45%) for uterine carcinosarcoma compared with 68% (95% CI 63-73%) for grade 3 endometrioid carcinoma. For stage III, survival was 22% (95% CI 19-26%) for uterine carcinosarcoma compared with 45% (95% CI 41-49%) for grade 3 endometrioid carcinoma. CONCLUSION: Carcinosarcomas present at more advanced stage and have worse survival than grade 3 endometrioid carcinomas. Carcinosarcomas may represent a distinct biologic entity. LEVEL OF EVIDENCE: II

OBJECTIVE: We examined the effect of radiation on survival for early-stage uterine carcinosarcomas and leiomyosarcomas. STUDY DESIGN: The surveillance, epidemiology, and end results database was used to identify patients with stage I/II carcinosarcomas and leiomyosarcomas. Logistic regression and Cox models were developed to determine radiation use and survival. RESULTS: Among 1819 women with carcinosarcomas and 1088 women with leiomyosarcomas, radiation was administered to 667 of the patients (37%) with carcinosarcomas and to 235 of the patients (22%) with leiomyosarcomas. In a multivariate model, adjuvant radiation reduced the risk of death by 21% in women with carcinosarcomas (hazard ratio, 0.79; 95% CI, 0.7-0.9). Radiation reduced mortality rates in patients with carcinosarcomas who had not undergone node dissection but had only a marginal effect on survival in node-negative women. Adjuvant radiation had no effect on survival for early-stage leiomyosarcomas (hazard ratio, 1.1; 95% CI, 0.9-1.4). CONCLUSION: Adjuvant radiotherapy improves survival for select patients with early-stage carcinosarcomas but is of limited value for leiomyosarcomas

BACKGROUND: Preoperative chemoradiation for advanced vulvar cancer reduces the tumor size and decreases morbidity from operative resection. CASE: A woman with locally advanced vulvar cancer had no evidence of metastatic disease at presentation. She displayed complete resolution of her vulvar and groin disease but developed early metastatic spread to the lungs and bone. CONCLUSION: Despite excellent local control, patients with locally advanced vulvar cancer are at risk for early metastatic spread. The effect of delayed surgical intervention, ifany, is unknown

Skin injury is a common side effect of breast-cancer radiation therapy. Although physicians often observe skin toxicity, quantifying its severity remains a challenge. We present a novel quantitative ultrasonic technique to evaluate skin changes associated with radiotherapy. An in vivo study with twelve breast-cancer patients was conducted. All patients received a standard course of post-surgery radiation therapy. Each patient received ultrasound scans to the irradiated breast and the untreated (contra-lateral) breast. Radio-frequency (RF) backscatter signals and B-mode images were acquired simultaneously. To quantify the severity of skin injury, two metrics were calculated from the RF signals: skin thickness and Pearson correlation coefficient of the subcutaneous layer. Comparing to the non-irradiated skin, the average thickness of the irradiated skin increased by 40% (p=0.005) and the average correlation coefficient of the irradiated hypodermis decreased by 35% (p=0.02). This study demonstrates the feasibility of using a non-invasive ultrasonic technique to detect and quantify radiation-induced skin changes