From 1977 to 1982, 189 patients with clinical Stage I and II breast cancer underwent excisional biopsy and axillary node dissection followed by definitive radiotherapy at the University of Pennsylvania. One hundred and nine patients had T1 lesions and 80 had T2 lesions. Histologically negative nodes were found in 136 patients (72%) and histologically positive nodes in 53 patients. Seventy-four percent of those with positive nodes had 1-3 positive nodes. Median follow-up from the completion of radiotherapy was 26 months. The cumulative probability of local-regional failure only at 48 months is 5%. The incidence of local recurrence was unrelated to T stage or nodal status. Regional failure was unrelated to T stage, but appeared more frequently in node positive patients. Three patients have died, two of disease and one of an unrelated cause. Ten patients are alive with disease. The four year actuarial disease free survival is 82% for pathologic Stage I (T1, pathologic N0) and 70% for pathologic Stage II (T1 pathologic N1, T2 pathologic N0 or N1). Cosmesis was judged to be good to excellent in 90% and fair in 9%. Complications included arm edema (7%), symptomatic pneumonitis (1%), rib fractures (1%), pericarditis (1%) and pleural effusion (1%). No patient experienced a brachial plexus injury. Primary radiotherapy for Stages I and II breast cancer produces a local-regional control rate of 95% and good to excellent cosmesis in 90% of the patients. While these results are preliminary, they compare favorably with other reported series.

In patients being treated with breast conserving surgery and primary irradiation for breast cancer, adequate treatment of the primary tumor bed is associated with improved local control rates. This report presents a practical method for defining the tumor bed. At the time of excisional biopsy, radiopaque surgical clips are placed at the margins of the tumor bed. These clips are used to localize the tumor volume for the simulation of the breast tangents and for planning the boost field. This technique will minimize the potential for a geographic miss during definitive irradiation for breast cancer.

The treatment of early (stage I and II) breast cancer over the past 10 years has shown a trend towards conservative use of surgery. The role of mastectomy in achieving local-regional control has been challenged by procedures that preserve the breast, in which tumor excision and axillary node dissection are followed by breast irradiation. Data from retrospective studies as well as prospective randomized trials have shown that in selected patients conservative surgery and radiation achieve results comparable to those of mastectomy in terms of 10-year survival and local-regional recurrence. Studies have shown that conservative surgery, radiation, and adjuvant chemotherapy can be combined effectively in patients at high risk for systemic disease. Although the optimal treatment of early breast cancer remains controversial, the non-mastectomy approach represents major progress.

BETWEEN 1977 AND 1982, 34 BREAST CANCERS IN 33 women aged ≤35 years were treated with primary radiotherapy following excisional biopsy and axillary lymph node dissection. The records of these cases were reviewed and compared to 156 women > age 35 with 157 breast cancers treated similarly during the same time period. Analysis of these cases was limited to patients with invasive cancers who were AJC Stages I or II. In the women ≤ age 35, there were only six failures (two with locoregional failure only and four with distant metastases). The treated breast was preserved in all of the younger women except for the two patients with locoregional failure only who were treated for salvage with a mastectomy. The actuarial freedom from breast relapse alone at 3 years was 96% in women ≤ 35 years vs. 97% in women > 35 years. Freedom from locoregional relapse only was 88% vs. 95% at 3 years in the above groups, and the actuarial disease-free survival at 3 years was 76% vs. 87%, respectively. None of the above comparisons between younger and older women are statistically different. We conclude that definitive radiation therapy for Stages I and II carcinoma of the breast in women ≤ age 35 yields similar results to those for women > 35. Such treatment achieves excellent preservation of the breast and should continue to be considered as an alternative to mastectomy.

The continuing appearance of reports of the experience of single institutions with conservative surgery and radiotherapy in the treatment of early breast cancer has strengthened the argument that this form of treatment exists as an acceptable alternative to mastectomy and expands our understanding of the non-mastectomy approach. in this issue, Hiry et al. review their results in treating 107 patients with primary tumors less than 3.5 centimeters over a five year period from 1975 to 1980. With limited follow-up, the authors report a five year actuarial survival of 95%. This figure is quite comparable to the five year survival rates of 90%” and 95%9 reported from Milan and the Gustave-Roussy, both of which represent prospective randomized trials. The extent of the initial surgical procedure in the breast and axilla has remained controversial. The present authors advocate segmental resection of the primary with or without the overlying normal skin. The breast recurrence rate of 6% (7/108) would support this recommendation. All of the seven breast recurrences occurred within the initial biopsy site and four of the seven occurred within the first two years following treatment. This early pattern of recurrence is more commonly associated with the use of an incisional biopsy’,5 or treatment of T2 lesions.lV5 Surgical diligence in obtaining complete gross tumor removal is, therefore, crucial to the success of the more limited excisional biopsy procedures. The authors recommend axillary node dissection as the appropriate procedure to accurately assess the status of the axilla. Their observation that the three cases of axillary recurrence occurred in patients in whom only four nodes were examined pathologically adds further data to support the greater incidence of axillary recurrence4 and skip metastases* (positive level II or III nodes with negative level I) when less than 10 nodes are available for histologic analysis. The overall low incidence of regional recurrence, however, justifies the policy of omission of regional node irradiation in outer quadrant lesions with a pathologic negative axilla and suggests that the policy could be extended to inner quadrant or central lesions with a negative axilla. Breast recurrence was related to the total breast dose and as noted by others3.5.6%7 was unrelated to the primary tumor size, the location of the primary, or the axillary node status. Total doses greater than 4500 rad to the entire breast do not appear indicated in terms of local control and clearly diminish cosmesis. It is of note that two of the seven breast recurrences were associated with widespread microcalcifications. For some investigators3 this has been a relative contraindication to primary radiotherapy. The use of Cobalt-60 therapy for the boost treatment in the present series has produced cosmetic results and local control rates comparable to those achieved by an electron beam’,” or interstitial Iridium192 implant6 The present report adds to the growing number of single institution retrospective series employing conservative surgery and radiotherapy for the treatment of early breast cancer. While the results are preliminary, they are in agreement with those reported from both randomized and non-randomized studies. As experience is gained with the non-mastectomy approach, treatment guidelines are developed and technical improvements are made to maximize cosmesis and minimize localregional recurrence and complications. The evidence to support conservative surgery and radiation as an alternative to mastectomy continues to accumulate and hopefully will promote its acceptance as a valid treatment option within the community.

Between July 1, 1979 and March 1, 1984, we treated 154 women by irradiation as an alternative to mastectomy. Excision of the primary tumor without the sacrifice of a large volume of contiguous normal breast (lumpectomy) was performed, and all but ten women also underwent concomitant level I axillary node dissection. The mean node count in the level I dissection was 27 nodes, indicating that this dissection offered accurate information about axillary node status, so that the extent of radiation therapy and subsequent adjuvant chemotherapy could be planned appropriately. Subdivision of the level I nodes into anatomic groups and their separate histologic analysis suggested that less than a complete level I dissection might miss involved nodes in almost one-half the patients with clinically negative axillae but histologically positive nodes. Postoperative complications occurred in 13% of patients, not an insignificant number, most of them being either infections or the persistent accumulation of lymph in the axillary wound. Later complications, such as infection or arm edema, also occurred, just as after mastectomy. The median follow-up of these 154 patients has been only 12 months, the maximum being not quite 5 years, so that any long-term speculations are not justified. We believe that the continued use of this combination therapy is warranted preceding irradiation by lumpectomy and level I axillary dissection as described, with careful follow-up to assess the long-term results of this option.

Considering the choice of treatment for “early” breast cancer controversial might be likened to calling a monsoon a small rainfall. Enthusiastic and vocal advocates of widely disparate forms of therapy resemble carnival barkers hawking their games, promising a prize with each toss. At one extreme are those who believe that no one any longer must submit to mastectomy, and at the other end are those who refuse to consider anything but mastectomy. In the middle of this maelstrom of rhetoric stands the all-but forgotten patient, who, quite understandably, feels that half of her is being pulled inexorably toward the linear accelerator while the other half is being drawn into the operating room. Not only is this decision between mastectomy and radiation therapy thrust upon the patient when she is most vulnerable, but the patient is all too often made to feel that the decision must be made immediately, any delay between biopsy and therapy jeopardizing the ultimate chances of survival.

From 1978 to 1981, 46 patients received primary radiotherapy following excisional biopsy and axillary staging procedure for Stages I and II carcinoma of the breast. The patients were divided into 2 groups: 27 patients who received radiation and completed 12 cycles of adjuvant chemotherapy (CMF or CMFP) and 19 patients who received radiation alone. All patients received radiation to the breast and regional nodes (4600-5000 rad) and a boost to the site of the primary tumor (1500-2000 rad). Median follow-up from completion of radiation was 26 months in the non-adjuvant and 24 months in the adjuvant group with a range of 12 to 49 months. Cosmesis was judged to be good to excellent in 89% (17/19) of the patients receiving radiation alone and 81% (22/27) of the patients receiving adjuvant chemotherapy. Fair to poor cosmesis in the adjuvant group was attributed primarily to increased fibrosis and reduction of breast size. The single complication for which there was an increased incidence in the adjuvant group was arm edema (22 vs. 0%). The incidence of arm edema was unrelated to T stage, type of axillary surgical procedure, number of positive nodes, addition of prednisone or sequencing of chemotherapy. Further efforts should be directed towards minimizing complications and maximizing cosmesis without sacrificing relapse-free survival in patients receiving primary radiotherapy and adjuvant chemotherapy for early breast cancer.

An interview questionnaire was developed to assess quality of life both in objective and subjective terms in cancer patients. Standardized measures were employed and allowed for comparison with a national baseline. Three hundred thirty-nine patients who were alive without evidence of disease 3 or more years following initial treatment were interviewed. There was no difference in terms of educational level, marital status, or satisfaction with local government, family, job, friends, community, health, recreation, or activities when compared to the age-adjusted national baseline. The patients were more satisfied with region, self, and life as a whole. There was no evidence of a diminished quality of life in these patients.

Two cases of advanced (Stage III) carcinoid. tumors of the cervix are presented. Initial treatment in both cases consisted of combination chemotherapy (CCNU, cyclophosphamide and methotrexate) administered in the same regimen used in the treatment of small cell carcinoma of the lung. Initial response in the first case was remarkable, but toxic side effects delayed further treatment. Local tumor progression followed resulting in bilateral complete ureteric obstruction. Radiation therapy was discontinued before an effective dose could be delivered, and the patient expired in uremic coma. In the second case, initial response to chemotherapy was not as effective, but radiation therapy seemed to produce local control of the disease. Review of the English literature produced 21 additional cases of carcinoid tumors of the cervix: eight Stage I, seven Stage II, four Stage III, and one Stage IV. No firm conclusions with regard to therapy could be drawn from such small numbers.

A group of 72 patients who had received radiotherapy between 1972 and 1980 for isolated local-regional recurrence of breast cancer was studied; 38 had received adjuvant chemotherapy and 34 had not. The two groups were comparable except for the initial nodal status and median time from mastectomy to recurrence. Outcome was not significantly different for the two groups in terms of response to radiotherapy, incidence of re-recurrence, distant metastases, and three-year survival. The length of the disease-free interval and the response to radiotherapy were the only factors studied that were significantly related to survival.

Between 1961 and 1978, 19 patients with a diagnosis of childhood or teenage craniopharyngioma received supervoltage radiotherapy. All patients had previously undergone either partial surgical resection (10 patients), total gross resection (3 patients), or aspiration and biopsy (6 patients). Fourteen patients were treated primarily and five were treated for recurrence. The five-year survival was 73% with a 10-year survival of 64%. Sixteen percent developed a recurrence following radiotherapy. Long term effects were assessed in terms of neurologic, intellectual, psychological and endocrine function. Seventy-nine percent had none or minimal neurologic disability. The mean full scale IQ for the group was 90. There were no additional endocrine deficiencies that could be directly attributed to radiation. Behavioral disorders occurred in 50%. These results are at least comparable, if not superior, to those of surgery.

One-hundred-twelve children with primary brain tumors received definitive radiotherapy between the years 1958--1979. Sixty-nine patients were alive at intervals of 1--21 years. Thirty-eight patients underwent neurologic and endocrine evaluation, psychologic and intelligence testing, and assessement for second malignancy post-treatment. A second intracranial malignancy developed in one child, for an incidence of 1.6%. Performance status was good to excellent in 89% of the patients studied. Seventeen percent of the group were mentally retarded. Behavioral disorders were identified in 39% of the patients, 59% of the mothers, and 43% of the fathers. Of the 23 patients with nonparasellar tumors, six were found to have growth hormone deficiency, including two patients with panhypopituitarism. Disability was related to age under 3 years at the time of treatment and tumor extension to the hypothalamus.

Optic nerve gliomas represent one to five percent of all intracranial tumors in children. The management of these tumors remains controversial. From 1956 to 1977, 18 children with optic nerve gliomas were treated at Thomas Jefferson University Hospital using external beam radiotherapy. All children presented with decreased visual acuity and five of eighteen were blind in one eye. No patient was found to have involvement of a single optic nerve. In eight patients, the chiasm was involved, in ten patients, tumor had extended to the frontal lobes and/or hypothalamus. Initial surgical management included biopsy only in seven patients, inspection of tumor in two patients and partial excision in seven patients. Two patients were treated with radiotherapy based on radiological findings. A tumor dose of 5000–6000 rad was given in 5.5–6.5 weeks. Stabilization of visual impairment or improvement in vision was noted in 78 percent of patients who were evaluable. The ten year survival was 73 percent. Radiological evidence of tumor regression will be presented.

From 1967 to 1977 at Thomas Jefferson University Hospital 281 patients with endometrial carcinoma received radiotherapy. Thirty-two patients had Stage III disease. Nineteen patients had clinical Stage III disease and 13 patients had pathologic Stage III disease based on findings following total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO). Follow-up ranged from two to nine years. crude five-year survival rates of 11.7% for clinical Stage III carcinoma of the endometrium and 44% for pathologic Stage III were observed. Local control was achieved in 92% of the patients whose clinical Stage III disease was treated definitively and in all patients whose pathologic Stage III disease was treated postoperatively. Distant metastases occurred in 58% of the clinically staged patients and 23% of the pathologically staged patients. Adjuvant chemotherapy is recommended.