Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials.

A review was done of 120 cases of malignant peripheral nerve sheath tumor (MPNST) seen during a 71-year period. Of the 120 patients, 52 were males and 68 were females with a mean age at diagnosis of 35.3 years; 12 patients were younger than 20 years. The series included 62 (52%) patients with neurofibromatosis, 13 (11%) with postradiation sarcomas, and 19 (16%) with metaplastic foci. The incidence of MPNST arising in neurofibromatosis was 4.6% in the current series and 0.001% in the general clinic population. Tumors greater than 5 cm and the presence of neurofibromatosis adversely affected the prognosis (P less than 0.05). When both features were present, survival was greatly decreased. Patients with tumor in the extremities did better than those with head or neck lesions. Metaplastic foci or previous radiation at the tumor site did not alter the prognosis. Each tumor was graded 1 to 4 on the basis of cellularity, pleomorphism, mitotic index, and necrosis. No significant correlation was noted between survival and either grade or mitotic rate. Survival was improved when total rather than subtotal resection was done. This was most marked in patients with a small lesion, which may reflect the difficulty in adequately excising large tumors. Adjuvant radiation or chemotherapy did not appear to affect survival. The MPNST is an aggressive uncommon neoplasm, and large tumor size, the presence of neurofibromatosis, and total resection are the most important prognostic indicators.

Malignant peripheral nerve sheath tumors. A clinicopathologic study of 120 cases.

PURPOSEThis randomized, prospective study assesses the impact of postoperative external-beam radiation therapy on local recurrence (LR), overall survival (OS), and quality of life after limb-sparing resection of extremity sarcomas.PATIENTS AND METHODSPatients with extremity tumors and a limb-sparing surgical option were randomized to receive or not receive postoperative adjuvant external-beam radiotherapy. Patients with high-grade sarcomas received postoperative adjuvant chemotherapy whereas patients with low-grade sarcomas or locally aggressive nonmalignant tumors were randomized after surgery alone.RESULTSNinety-one patients with high-grade lesions were randomized; 47 to receive radiotherapy (XRT) and 44 to not receive XRT. With a median follow-up of 9.6 years, a highly significant decrease (P2 = .0028) in the probability of LR was seen with radiation, but no difference in OS was shown. Of 50 patients with low-grade lesions (24 randomized to resection alone and 26 to resection and postoperative XRT), th...

Randomized prospective study of the benefit of adjuvant radiation therapy in the treatment of soft tissue sarcomas of the extremity.

The pathological features of 155 adult patients with soft-tissue sarcomas were studied retrospectively, in an attempt to set up a grading system for these tumors. As the first step, seven histological criteria (tumor differentiation, cellularity, importance of nuclear atypia, presence of malignant giant cells, mitosis count, pattern of tumor necrosis and presence of vascular emboli) were evaluated in a monofactorial analysis. Five of these (tumor differentiation, cellularity, mitosis count, tumor necrosis, and vascular emboli) were correlated with the advent of metastases and with survival. A multivariate analysis, using a Cox model, selected a minimal set of three factors (tumor differentiation, mitosis count, and tumor necrosis) the combination of which was necessary and sufficient to retain all the prognostic information. A grading system was elaborated, which turned out to be correlated with the advent of metastasis and with patients' survival. A second multivariate analysis introducing clinical prognostic features showed that the histological grade was the most important prognostic factor for soft-tissue sarcomas. Thus, this grading system appears to be highly interesting because of its prognostic value and the facility of its elaboration. However, its reproducibility should be tested.

Soft‐tissue sarcomas of adults; study of pathological prognostic variables and definition of a histopathological grading system

OBJECTIVE: To analyze treatment and survival of a large cohort of patients with retroperitoneal soft-tissue sarcomas (STS) treated and prospectively followed at a single institution. SUMMARY BACKGROUND DATA: Retroperitoneal STS are relatively uncommon and constitute a difficult management problem. Although surgical resection is often difficult or impossible, current chemotherapy is not effective and radiation is limited by toxicity to adjacent structures. Thus, complete surgical resection remains the most effective modality for selected primary and recurrent disease. METHODS: Five hundred patients with retroperitoneal STS were admitted and treated between July 1, 1982, and September 30, 1997, and prospectively followed. Patient, tumor, and treatment variables were analyzed for disease-specific and disease-free survival. Survival was determined with the Kaplan-Meier method. Statistical significance was evaluated using the logrank test for univariate influence and Cox model stepwise regression for multivariate influence. RESULTS: Two hundred seventy-eight patients (56%) had primary disease and 222 (44%) recurrent disease. Median follow-up was 28 months (range 1 to 172 months), 40 months for survivors. Median survival was 72 months for patients with primary disease, 28 months for those with local recurrence, and 10 months for those with metastasis. For patients with primary or locally recurrent tumors, unresectable disease, incomplete resection, and high-grade tumors significantly reduced survival time. CONCLUSIONS: In this study of patients with retroperitoneal STS, stage at presentation, high histologic grade, unresectable primary tumor, and positive gross margin are strongly associated with the tumor mortality rate. Patients approached with curative intent should undergo aggressive attempts at complete surgical resection. Incomplete resection should be undertaken only for symptom relief.

Retroperitoneal soft-tissue sarcoma: analysis of 500 patients treated and followed at a single institution.

From January 1963 through December 1977, 300 adults with soft-tissue sarcomas were treated by a conservative surgical excision and postoperative radiotherapy. The absolute two- and five-year disease-free survival rates are 74% (222/300) and 61.3% (103/168), respectively. The five-year survival rate varies with: (1) anatomic site, e.g., 69.4% (75/108) for extremity lesions vs. 33% (5/15) for abdominal lesions; (2) histopathologic diagnosis, e.g., 86.4% (19/22) for fibrosarcoma vs. 50% (15/30) for neurofibrosarcoma; and (3) stage of the lesion. The overall local recurrence rate was 22.3% (67/300) and 27% (81/300) of the patients developed distant metastases. The incidence of lymph node metastases as an initial site of spread was only 2.7% (8/300); therefore, elective treatment of the regional lymphatics is not indicated. The 6.5% incidence of significant complications in extremities is low and might be further diminished by careful treatment planning. The combination of conservative surgery and postoperative radiation therapy maintains a functional limb in 84.5% (169/200) of patients with extremity lesions. This rate is comparable to the five-year survival rate attained with radical surgery.

Conservative surgery and postoperative radiotherapy in 300 adults with soft-tissue sarcomas

Fifty‐three patients with inoperable but regionally localized non‐oat cell bronchogenic carcinoma were evaluated in a prospective randomized study of the use of split‐course irradiation alone and split‐course irradiation used in conjunction with hydroxyurea. The 25 patients receiving irradiation alone had 1‐ and 2‐year absolute survivals of 48% and 12% respectively, whereas the 28 patients receiving irradiation plus hydroxyurea had 46% 1‐year and 11% 2‐year survivals. Survival in the split‐course irradiation group was comparable at 2 years to that in a previous, similar group of patients irradiated continuously, but slightly inferior in terms of long‐term survivors. The split‐course rest period affords important patient observation time, permitting the elimination of unnecessary further irradiation in those patients who develop early distant metastases.

Split-course irradiation compared to split-course irradiation plus hydroxyurea in inoperable bronchogenic carcinoma--a randomized study of 53 patients.

Sixty-five patients with small cell bronchogenic carcinoma received their first two of three courses of intensive induction chemotherapy with (30 patients) or without (35 patients) intravenous hyperalimentation (IVH). Patients predominantly had extensive disease (55%), Zubrod's performance status 0 to 2 (63%) and 6% pretreatment weight loss (68%). Both treatment arms were comparable by prognostic factors. The chemotherapy included six remission induction courses of ECHO chemotherapy (E: epipodophyllotoxin VP-16–213; C: cyclophosphamide; H: hydroxydaunorubicin; O: oncovin [vincristine]) followed by six courses of maintenance with PRIME (PR: procarbazine; I: ifosfamide; ME: methotrexate). Prophylactic brain irradiation was given to all patients. Patients with limited disease received chest irradiation at the completion of ECHO. Fifty of 52(96%) evaluable patients responded with a complete (56%) or partial (40%) remission. The complete remission (CR) rate was higher in the control arm (66% versus 43%; P = 0.11). Response duration and survival of patients was similar for both treatment arms. Combined median survival duration for all patients with limited and extensive disease was 15.75 and 11.50 months, respectively. Combined median survival duration for CR patients with limited and extensive disease was 25 and 13 months, respectively. Administration of IVH did not ameliorate the hematologic, gastrointestinal and infectious morbidity of ECHO chemotherapy. The IVH was effective in preserving body weight and improving delayed hypersensitivity reaction to a battery of skin test antigens. Administration of intensive ECHO chemotherapy to patients with small cell bronchogenic carcinoma resulted in high response rates, acceptable toxicities and improved survival. Administration of IVH did not improve the short- and long-term results of chemotherapy, and did not ameliorate its morbidity. Nutritional support, however, was helpful in preventing patient's weight loss. Cancer 59:362–369, 1987.

Long-term effects of intravenous hyperalimentation administered during intensive chemotherapy for small cell bronchogenic carcinoma.

Between January 1977 and February 1980, 95 patients with inoperable squamous carcinomas of the head and neck were treated in a two-armed randomized clinical trial comparing 1) mixed schedule irradiation using two neutron and three photon fractions per week and 2) standard photon irradiation. Complete tumor regression was achieved in 80% of patients treated with mixed-schedule irradiation, and in 68% of patients treated with photons. The local control rate was 44% in patients treated with mixed-schedule irradiation and 41% in patients treated with photons. There were four complications of treatment in each treatment arm. Absolute survival was 20% with mixed-schedule treatment and 17% in photons. Actuarial analysis shows superior local control and survival rates with mixed-schedule irradiation over photons only in the first two years.

Neutron therapy for head and neck cancer: II. Further follow-up on the M. D. Anderson TAMVEC randomized clinical trial.

The current enthusiasm for polychemotherapy in small cell undifferentiated bronchogenic carcinoma obscures the necessity for primary control by radiation therapy. One hundred and sixty-three patients with this diagnosis were treated in the periods 1965-67 (56) and 1974-76 (107). In the earlier period patients received radiation alone or radiation plus single-agent chemotherapy. In the latter period, all patients were treated with multiple-agent chemotherapy in addition to radiation therapy. Median survival time was extended approx. 4 weeks for the latter group of patients at the cost of much morbidity and occasional lethality. In the patients that were autopsied from both series, only 5/30 were free of disease within the treatment portals and all had received more than 4000 rad tumor dose regardless of adjuvant therapy. A total of 14 autopsies were performed on patients treated by chemo-immunotherapy alone during the 1974-76 period. All of these revealed disease in the primary site and mediastinum although some had no evidence of distant metastasis. Tumor volume is sufficiently large within the primary site and regional lymphatics that presently available chemoimmunotherapy without high dose irradiation is unlikely to sterilize loco-regional disease. Elective radiation to the whole brain was administered to 25 patients and only 3 developed cerebral metastases. Of the remaining 82 patients who were treated concurrently, 25 developed cerebral metastasis and then received radiation therapy to the whole brain, 10 of these patients subsequently died.

H. Thomas Barkley

Papers

Conservative surgery and postoperative radiotherapy in 300 adults with soft-tissue sarcomas

Split-course irradiation compared to split-course irradiation plus hydroxyurea in inoperable bronchogenic carcinoma--a randomized study of 53 patients.

Long-term effects of intravenous hyperalimentation administered during intensive chemotherapy for small cell bronchogenic carcinoma.

Neutron therapy for head and neck cancer: II. Further follow-up on the M. D. Anderson TAMVEC randomized clinical trial.

The role of radiation therapy in the treatment of small cell undifferentiated bronchogenic cancer