- Email: [email protected]
Leiomyosarcoma of the prostate apparently cured by surgery and radical irradiation: Report of a case
1814
Radiation
Oncology
to stem cells. Moss> suggested that radiosensitivity to the location of the marrow.
0 Biology
0 Physics
October
1982, Volume
8, Number
IO
may vary according
CONSTANTINF G. PAPAVASILIOV. Director of Radiotherapy Radiotherapy Laboratory Alexandra University Hospital 61 I Athens. Greece
M.D.
I. Aristioazal. S.A., Runyon, T.D.: Radiotherapy of unusual benign 1981. disease. Inr. J. Radial. Oncol. Biol. Phys. 7:1437-1440, 2. Close. A.S., Yoshira. T., Cleveland, D.A.: Spinal cord compression due to extramedullary hematopoiesis. Am. Inr. Med. 48:421-427. 1958. 3. Gatto, I., Terrana, V., Biondi, L.: Compressione sul midollo spinal da proliferazione di Midollosseo sphrio epidinale in soggeto affetto da malatia di Cooley speloctomizzato. Haematologica 38:6 I-75.
1964. 4. Lowman. R.M., Bloor. C.M., Newcomb. A.W.: Rijentgen manifestations of thoracic extramedullary hematopoiesis. Dis Chest. 44: I 54m 162. 1963. 5. Moss. W.T.: Therapeutic Radiology. St. Louis, The C.V. Mosby Company, 1959. 6. Papavasiliou, C.: Tumor-simulating intrathoracic extramedullary hemopoiesis. Am. J. Riienrgenol. 93:695-702, 1965. I. Papavasiliou, C., Konstantoulakis. M., Priovolos, J.. Labrakos. B.. Agrogrannis, E.. Manettas. S.. Papadysseas. S.. Pippis. P.: The anterior costal margin mass in patients with Thalassemia major.
Clin. Radiol. 30:52 I-524,
1919.
9. Rubin, P.. Scarantino, C.W.: The bone marrow organ. The critical structure in radiation-drug Interaction. fnl. J. Radiar. Oncol. Biol.
Phys. 4:3- 23. 1978. 10. Sorsdahl. OS., Taylor, P.E., Moyes, W.D.: Extramedullary topoiesis mediastinal masses and spinal cord compression. 189:343-347.
hema-
JAMA
1964.
OF THE PROSTATE APPARENTLY CURED BY SURGERY AND RADICAL IRRADIATION: REPORT OF A CASE
Fig. I, Histologic appearance of Leiomyosarcoma involving prostate (H & E x 200). Insert demonstrates mitosis and fine nuclear detail (H & E x 1100). our hospital. The true pelvis was treated by a 4 MeV photon beam using two parallel opposed anterior and posterior ports (I3 x I4 cm.), delivering 4,800 rad by split course during 50 days. During the period of split of two weeks the tumor bed area was boosted using 360” rotation (8 x 8 cm.) for an additional 2,000 rad (total NSD I.897 ret). The patient tolerated radiotherapy without side effects; no complications developed. He was evaluated by a medical oncologist who indicated that chemotherapy was not necessary. Seven months after the prostatectomy repeat cystourethroscopy with muliple biopsies of the bladder base and prostate railed to demonstrate any residual malignant neoplasm. Three months later the temporary colostomy was closed with no evidence of any abdominal pelvic tumors or abnormalities. The patient IS currently alive and well and is free of neoplastic recurrence or metastasis five years
later.
LEIOMYOSARCOMA
To rhe Editor: Leiomyosarcoma
of the prostate is a rare tumor. and reports of its management are even more uncommon. In this communication we present a patient with leiomyosarcoma who responded favorably to radiotherapy. We also report a brief review of the literature.
Case reporr A 66 year-old
Caucasian male presented with a three month history of rectal pain. poor stream and frequency of micturition. Rectal examination and intravenous pyelogram revealed an enlargement of the median lobe of the prostate. The patient subsequently underwent a suprapubic prostatectomy. A fleshy firm mass replaced the posterior lobe of the prostate and was attached posteriorly to the rectum. Dissection of this mass was later complicated by the development of a vesico-rectal fistula which was surgically closed. A sigmoid colostomy was performed. The tumor measured 8 x 7 x 4.5 cm. and weighed 206 gm. It was a firm, greyish nodular mass. Microscopic examination of the tumor demonstrated a slightly pleomorphic fusiform smooth muscle cells arranged in whorled and streaming pattern. Mitosis number up to five per IO high powered fields (Figure I). The features were diagnostic of leiomyosarcoma. Sections from nearby prostate tissue revealed benign stromal. glandular hyperplasia of the prostate. No lymph glands could be detected in the tissues submitted. A urologist was consulted and a week later a cystourethroscopy was performed. The area of the fistula in the bladder showed some fibrin and edematous mucous tag. The remainder of the bladder mucosa revealed injunction and prostatic incrustation. The rectal examination revealed a retracted area at the site of the fistula, which was healed. Biopsy from the prostatic bed showed a mixture of inflammatory cells. Because of probable residual microscopic disease and the limited surgical procedure the patient was referred for adjuvant radiotherapy at
Sarcoma of the prostate numbers less than 0.1% of all malignant prostate tumors.‘.‘.9 When it affects children (mostly first decade), it is usually in the form of rhabdomyosarcoma which has a very poor prognosis despite aggressive combined therapy.“““,” Sarcoma of the prostate can also involve elderly patients (median age 58 years),‘usually in the form of leiomyosarcoma or fibrosarcoma. Lymphatic and vascular spread are common,‘9 although lymph node metastases is rare. Other rare tumors that involve the prostate include: angiosarcoma. malignant fibrous histiocytoma. chondrosarcoma. osteogenic sarcoma. neurogenic sarcoma and neuroblastoma.’ Leiomyosarcoma might be dilficult to distinguish from stromal hyperplasia.‘,’ which has a benign course. The latter condition is associated with neither bulky masses, nor infiltration of the surrounding organs. It is also characterized by absence of mitotic figures.” According to Mindich ef a/.6 each tumor should be considered malignant if mitotic ligures are present. Others believe that there is no transformation from a benigh lesion to a malignant leiomyosarcoma.’ An increase in mitotic activity is regarded as a reliable criterion for malignancy, especially in uterine leiomyosarcoma.’ The diagnosis of leiomyosarcoma in this reported case was based on tumor-fixation to rectum (probably was a factor in inducing a listula). pleomorphic features are frequent mitotic figures. Stallwood and Davidson? reported a patient (without follow-up) similar to ours, whose tumor was apparently of prostatic origin, who required a transverse colostomy followed by radical abdominal perineal resection and a permanent sigmoid colostomy. After review of the literature it seems that there is no uniform pattern for managing these tumors.‘O Leiomyosarcoma of the prostate is characterized by local recurrence and distant metastases. The prognosis is usually poor.‘.O,q The average survival for all patients with leiomyosarcoma is 3.5 years. but is only seven months for those with poorly differentiated tumors9 However, favorable results have been reported when aggressive therapy is used.’ Reports of the response of these tumors to radiotherapy are
IX15
Correspondence controversial.‘,’ Vereecken cr a/.‘O reported a patient whose therapy failed (local recurrence and distant metastases) despite treatments with radical surgery and pre- and post-operative irradiation. The majority of the reported patients were treated by radical surgery.’ The use of chemotherapy (Cyclophosphamide)“’ has been reported with no prolongation of survival. We realize that it is difficult to draw definite conclusions from Just one reported case. However. our patient had a favorable prognosis and appears to be cured inspite of the limited surgery; this might indicate that a full course of irradiation after a debulking procedure could improve the outcome of this disease. WAGIH M. SHEHATA, M.D.. ABRAHAM A. KERR, M.D. HARRY H. Boss, M.D. THOMAS W. PANKE, M.D. RICHARD L. MEYER, M.D.
Department of Radiation Good Samaritan Hospital Cincinnati. OH 45220
F.F.R.
the adequacy of radiation have to be reconsidered.
to the internal
mammary
lymph nodes will
I.Fo%~RI) R. PROSIT!. M.D. Professor of Therapeutic Radiology Department of Therapeutic Radiology Yale University School of Medicine 333 Cedar Street Yew Haven. CT 06510
I. Strender, L.-E., Wallgren. .4., Arndt, J.. Arner, 0.. Bergstrom. J.. Blomstedt. B.. Granberg. P.-O.. Nilsson. B.. Raf. L... Silfversward. C.: Adjuvant radiotherapy in operable breast cancer: Correlation between dose and internal mammary nodes and propnosrs. Inr J. Radial. Oncol. Biol. Phvs 7: 1319 1325, 1981.
Oncology
I. Attah, E.B.. Powell. M.E.: Atypical stromal hyperplasia of the prostate gland. Am. J. Clin. Pafhol. 61: 324-321. 1971. 2. Chatterjee. A.C.: Leiomyosarcoma of the prostate. Brir. J. Urolog) 47: 577. 1975. 3. Guha, T.: Leiomyosarcoma of the prostate: A case report. Clin. Oncol. 5: 261-265, 1975. 4. Hamman. F.. Bischoff, W.: Histologic changes of a prostatic leiomyosarcoma, case report. Hely. Chir. Acfa 45: 297-300. 1978. 5. MacKenzie. A.R., Sharma. T.C., Whitmore, W.F.. Jr., Melamed. M.R.: Non-extirpative treatment of myosarcomas of the bladder and prostate. Cancer 28: 329-334. I97 I. 6. Mindich, R., Tykoy, H.. Littman. L.. Levowitz, B.S.: Leiomyosarcoma of rectum: report of case. Dis. Colon Recfum l8:233-236. 1975. 7. Mostoh, F.K., Price, E.B.: Tumors of fhe Male Genital Sy.yfem. Fascile 8. Washington, D.C. Armed Forces Institute of Pathology. 1973. pp. 253-356. 8. Schmidt, J.D., Welch, M.J.. Jr.: Sarcoma of the prostate. C‘ancer 37: 1908-1912, 1976. 9. Stallwood, G.. Davidson, J.W.: Leiomyosarcoma of the rectum and prostate. Can. J. Surg. 20:446-9, 1977. IO. Vereecken, R.L.. Lauweryns, J., Droohmano, A., Yan Dijck. M.: Leiomyosarcoma of the prostate: A case report. Europ. J. Ural. 3: 370-2, 1977. I I. Weismann, M.J., Gaeta. J.F., Albert, D.J.: Childhood urogenital sarcoma. J. Surg. Oncol. 4: lO9- I 16, 1972.
REBUTTAL: RELAPSE-FREE SURVIVAL IS NOT A GOOD MEASUREMENT OF SURVIVAL IN BREAST CANCER To the Edifor: Dr. Prosnit supposes that the benetit in relapse-free survival given to the patients of our trial’ by preoperative or postoperative radiotherapy eventually will improve their long run survival. It is true that most patients who have a relapse of breast cancer will die from distant metastases. Local and regional recurrences will often be detected earlier than distant metastases. but are generally only indicators of a high risk to develop distant metastases rather than the cause of them. It should be observed that the main reason for the better relapse-free survival of the patients treated with radiotherapy was their lovver rate of local and regional recurrences. About one-third of the patients who have been treated only surgically and who have had local recurrences are still without any sign of distant disease and the rates of distant metastases of the three treatment groups are much more similar than the rates of all relapses. The belief that a significantly improved relapse-free survival evcntually will improve the longevity. is dangerous since it may lead to a premature acceptance of new treatment modalities. It has recently led to the general acceptance of adjuvant cytotoxic chemotherapy as the routine treatment of breast cancer with nodal involvement. As after radiotherapy, long term survival data show that the survival benefit is much smaller than could have been expected from the benefit in recurrence-free survival. l..\Rb-ERIh
STR~~IX.R.
M.D.
.4KUI WAI I(;Rt h. M.D Radiumhemmet Karolinska Hospital S 104 01 Stockholm
CRITIQUE OF “ADJUVANT RADIOTHERAPY IN OPERABLE BREAST CANCER: CORRELATION BETWEEN DOSE AND INTERNAL MAMMARY NODES AND PROGNOSES” To fhe Editor: The data presented by Strender er al.’ for the Stockholm group on the results of adjuvant radiotherapy in operable breast cancer are of great interest to the radiotherapy community. In this paper, the authors show a statistical improvement in survival for the group of patients receiving preoperative radiation followed by mastectomy, but not for those who were treated with radiotherapy following mastectomy. A rather elaborate explanation is then given, suggesting that the post-mastectomy patients may have received inadequate radiation to the internal mammary lymph nodes. However. both pre-operative and post-operative irradiation resulted in a statistically significant benefit in relapse-free survival. Since virtually all patients who have an initial relapse of their breast cancer following mastectomy will eventually die of metastatic disease, a significant improvement in relapse-free survival is bound to be reflected in the long run by significant improvement in the death rate due to breast cancer as well. Therefore, the premise that only preoperative radiotherapy improves survival will not be the case, given a long enough follow-up, if the relapse-free survival data are correct. The subseauent conclusions about
Strender. L.-E.. Wallgren. A., Arndt. J.. Amer. 0.. Bergstrom, J.. Bjonstedt, B.. Granderg. P.-O., Nitsson. B., Raf. L.. Silfversward. C.: Adjuvant radiotherapy in operable breast cancer: Correlation between dose in internal mammary nodes and prognosis. In, J Radial. Oncol. Biol. Phvs. 7:1319- 1325. 19x1.
INTERSTITIAL
PNEUMONITIS: DOSE-RATE DOSE OF RADIATION
VS TOTAL
To fhe Edifor: Interstitial pneumonitis (IPn). whether idiopathic or virus-associated, is a frequent and usually lethal complication of allogeneic bone marrow transplantation. A recent report by Keane et al.* is valuable in that it calls attention to the possibility that the total radiation dose to lung may correlate directly with fatal idiopathic IPn. Several problems with their data, however, prompted the following comments. Our chief concern has to do with the probit regression analysis which they presented in their Fig. I. The UCLA data. which they showed in
Radiation
Oncology
to stem cells. Moss> suggested that radiosensitivity to the location of the marrow.
0 Biology
0 Physics
October
1982, Volume
8, Number
IO
may vary according
CONSTANTINF G. PAPAVASILIOV. Director of Radiotherapy Radiotherapy Laboratory Alexandra University Hospital 61 I Athens. Greece
M.D.
I. Aristioazal. S.A., Runyon, T.D.: Radiotherapy of unusual benign 1981. disease. Inr. J. Radial. Oncol. Biol. Phys. 7:1437-1440, 2. Close. A.S., Yoshira. T., Cleveland, D.A.: Spinal cord compression due to extramedullary hematopoiesis. Am. Inr. Med. 48:421-427. 1958. 3. Gatto, I., Terrana, V., Biondi, L.: Compressione sul midollo spinal da proliferazione di Midollosseo sphrio epidinale in soggeto affetto da malatia di Cooley speloctomizzato. Haematologica 38:6 I-75.
1964. 4. Lowman. R.M., Bloor. C.M., Newcomb. A.W.: Rijentgen manifestations of thoracic extramedullary hematopoiesis. Dis Chest. 44: I 54m 162. 1963. 5. Moss. W.T.: Therapeutic Radiology. St. Louis, The C.V. Mosby Company, 1959. 6. Papavasiliou, C.: Tumor-simulating intrathoracic extramedullary hemopoiesis. Am. J. Riienrgenol. 93:695-702, 1965. I. Papavasiliou, C., Konstantoulakis. M., Priovolos, J.. Labrakos. B.. Agrogrannis, E.. Manettas. S.. Papadysseas. S.. Pippis. P.: The anterior costal margin mass in patients with Thalassemia major.
Clin. Radiol. 30:52 I-524,
1919.
9. Rubin, P.. Scarantino, C.W.: The bone marrow organ. The critical structure in radiation-drug Interaction. fnl. J. Radiar. Oncol. Biol.
Phys. 4:3- 23. 1978. 10. Sorsdahl. OS., Taylor, P.E., Moyes, W.D.: Extramedullary topoiesis mediastinal masses and spinal cord compression. 189:343-347.
hema-
JAMA
1964.
OF THE PROSTATE APPARENTLY CURED BY SURGERY AND RADICAL IRRADIATION: REPORT OF A CASE
Fig. I, Histologic appearance of Leiomyosarcoma involving prostate (H & E x 200). Insert demonstrates mitosis and fine nuclear detail (H & E x 1100). our hospital. The true pelvis was treated by a 4 MeV photon beam using two parallel opposed anterior and posterior ports (I3 x I4 cm.), delivering 4,800 rad by split course during 50 days. During the period of split of two weeks the tumor bed area was boosted using 360” rotation (8 x 8 cm.) for an additional 2,000 rad (total NSD I.897 ret). The patient tolerated radiotherapy without side effects; no complications developed. He was evaluated by a medical oncologist who indicated that chemotherapy was not necessary. Seven months after the prostatectomy repeat cystourethroscopy with muliple biopsies of the bladder base and prostate railed to demonstrate any residual malignant neoplasm. Three months later the temporary colostomy was closed with no evidence of any abdominal pelvic tumors or abnormalities. The patient IS currently alive and well and is free of neoplastic recurrence or metastasis five years
later.
LEIOMYOSARCOMA
To rhe Editor: Leiomyosarcoma
of the prostate is a rare tumor. and reports of its management are even more uncommon. In this communication we present a patient with leiomyosarcoma who responded favorably to radiotherapy. We also report a brief review of the literature.
Case reporr A 66 year-old
Caucasian male presented with a three month history of rectal pain. poor stream and frequency of micturition. Rectal examination and intravenous pyelogram revealed an enlargement of the median lobe of the prostate. The patient subsequently underwent a suprapubic prostatectomy. A fleshy firm mass replaced the posterior lobe of the prostate and was attached posteriorly to the rectum. Dissection of this mass was later complicated by the development of a vesico-rectal fistula which was surgically closed. A sigmoid colostomy was performed. The tumor measured 8 x 7 x 4.5 cm. and weighed 206 gm. It was a firm, greyish nodular mass. Microscopic examination of the tumor demonstrated a slightly pleomorphic fusiform smooth muscle cells arranged in whorled and streaming pattern. Mitosis number up to five per IO high powered fields (Figure I). The features were diagnostic of leiomyosarcoma. Sections from nearby prostate tissue revealed benign stromal. glandular hyperplasia of the prostate. No lymph glands could be detected in the tissues submitted. A urologist was consulted and a week later a cystourethroscopy was performed. The area of the fistula in the bladder showed some fibrin and edematous mucous tag. The remainder of the bladder mucosa revealed injunction and prostatic incrustation. The rectal examination revealed a retracted area at the site of the fistula, which was healed. Biopsy from the prostatic bed showed a mixture of inflammatory cells. Because of probable residual microscopic disease and the limited surgical procedure the patient was referred for adjuvant radiotherapy at
Sarcoma of the prostate numbers less than 0.1% of all malignant prostate tumors.‘.‘.9 When it affects children (mostly first decade), it is usually in the form of rhabdomyosarcoma which has a very poor prognosis despite aggressive combined therapy.“““,” Sarcoma of the prostate can also involve elderly patients (median age 58 years),‘usually in the form of leiomyosarcoma or fibrosarcoma. Lymphatic and vascular spread are common,‘9 although lymph node metastases is rare. Other rare tumors that involve the prostate include: angiosarcoma. malignant fibrous histiocytoma. chondrosarcoma. osteogenic sarcoma. neurogenic sarcoma and neuroblastoma.’ Leiomyosarcoma might be dilficult to distinguish from stromal hyperplasia.‘,’ which has a benign course. The latter condition is associated with neither bulky masses, nor infiltration of the surrounding organs. It is also characterized by absence of mitotic figures.” According to Mindich ef a/.6 each tumor should be considered malignant if mitotic ligures are present. Others believe that there is no transformation from a benigh lesion to a malignant leiomyosarcoma.’ An increase in mitotic activity is regarded as a reliable criterion for malignancy, especially in uterine leiomyosarcoma.’ The diagnosis of leiomyosarcoma in this reported case was based on tumor-fixation to rectum (probably was a factor in inducing a listula). pleomorphic features are frequent mitotic figures. Stallwood and Davidson? reported a patient (without follow-up) similar to ours, whose tumor was apparently of prostatic origin, who required a transverse colostomy followed by radical abdominal perineal resection and a permanent sigmoid colostomy. After review of the literature it seems that there is no uniform pattern for managing these tumors.‘O Leiomyosarcoma of the prostate is characterized by local recurrence and distant metastases. The prognosis is usually poor.‘.O,q The average survival for all patients with leiomyosarcoma is 3.5 years. but is only seven months for those with poorly differentiated tumors9 However, favorable results have been reported when aggressive therapy is used.’ Reports of the response of these tumors to radiotherapy are
IX15
Correspondence controversial.‘,’ Vereecken cr a/.‘O reported a patient whose therapy failed (local recurrence and distant metastases) despite treatments with radical surgery and pre- and post-operative irradiation. The majority of the reported patients were treated by radical surgery.’ The use of chemotherapy (Cyclophosphamide)“’ has been reported with no prolongation of survival. We realize that it is difficult to draw definite conclusions from Just one reported case. However. our patient had a favorable prognosis and appears to be cured inspite of the limited surgery; this might indicate that a full course of irradiation after a debulking procedure could improve the outcome of this disease. WAGIH M. SHEHATA, M.D.. ABRAHAM A. KERR, M.D. HARRY H. Boss, M.D. THOMAS W. PANKE, M.D. RICHARD L. MEYER, M.D.
Department of Radiation Good Samaritan Hospital Cincinnati. OH 45220
F.F.R.
the adequacy of radiation have to be reconsidered.
to the internal
mammary
lymph nodes will
I.Fo%~RI) R. PROSIT!. M.D. Professor of Therapeutic Radiology Department of Therapeutic Radiology Yale University School of Medicine 333 Cedar Street Yew Haven. CT 06510
I. Strender, L.-E., Wallgren. .4., Arndt, J.. Arner, 0.. Bergstrom. J.. Blomstedt. B.. Granberg. P.-O.. Nilsson. B.. Raf. L... Silfversward. C.: Adjuvant radiotherapy in operable breast cancer: Correlation between dose and internal mammary nodes and propnosrs. Inr J. Radial. Oncol. Biol. Phvs 7: 1319 1325, 1981.
Oncology
I. Attah, E.B.. Powell. M.E.: Atypical stromal hyperplasia of the prostate gland. Am. J. Clin. Pafhol. 61: 324-321. 1971. 2. Chatterjee. A.C.: Leiomyosarcoma of the prostate. Brir. J. Urolog) 47: 577. 1975. 3. Guha, T.: Leiomyosarcoma of the prostate: A case report. Clin. Oncol. 5: 261-265, 1975. 4. Hamman. F.. Bischoff, W.: Histologic changes of a prostatic leiomyosarcoma, case report. Hely. Chir. Acfa 45: 297-300. 1978. 5. MacKenzie. A.R., Sharma. T.C., Whitmore, W.F.. Jr., Melamed. M.R.: Non-extirpative treatment of myosarcomas of the bladder and prostate. Cancer 28: 329-334. I97 I. 6. Mindich, R., Tykoy, H.. Littman. L.. Levowitz, B.S.: Leiomyosarcoma of rectum: report of case. Dis. Colon Recfum l8:233-236. 1975. 7. Mostoh, F.K., Price, E.B.: Tumors of fhe Male Genital Sy.yfem. Fascile 8. Washington, D.C. Armed Forces Institute of Pathology. 1973. pp. 253-356. 8. Schmidt, J.D., Welch, M.J.. Jr.: Sarcoma of the prostate. C‘ancer 37: 1908-1912, 1976. 9. Stallwood, G.. Davidson, J.W.: Leiomyosarcoma of the rectum and prostate. Can. J. Surg. 20:446-9, 1977. IO. Vereecken, R.L.. Lauweryns, J., Droohmano, A., Yan Dijck. M.: Leiomyosarcoma of the prostate: A case report. Europ. J. Ural. 3: 370-2, 1977. I I. Weismann, M.J., Gaeta. J.F., Albert, D.J.: Childhood urogenital sarcoma. J. Surg. Oncol. 4: lO9- I 16, 1972.
REBUTTAL: RELAPSE-FREE SURVIVAL IS NOT A GOOD MEASUREMENT OF SURVIVAL IN BREAST CANCER To the Edifor: Dr. Prosnit supposes that the benetit in relapse-free survival given to the patients of our trial’ by preoperative or postoperative radiotherapy eventually will improve their long run survival. It is true that most patients who have a relapse of breast cancer will die from distant metastases. Local and regional recurrences will often be detected earlier than distant metastases. but are generally only indicators of a high risk to develop distant metastases rather than the cause of them. It should be observed that the main reason for the better relapse-free survival of the patients treated with radiotherapy was their lovver rate of local and regional recurrences. About one-third of the patients who have been treated only surgically and who have had local recurrences are still without any sign of distant disease and the rates of distant metastases of the three treatment groups are much more similar than the rates of all relapses. The belief that a significantly improved relapse-free survival evcntually will improve the longevity. is dangerous since it may lead to a premature acceptance of new treatment modalities. It has recently led to the general acceptance of adjuvant cytotoxic chemotherapy as the routine treatment of breast cancer with nodal involvement. As after radiotherapy, long term survival data show that the survival benefit is much smaller than could have been expected from the benefit in recurrence-free survival. l..\Rb-ERIh
STR~~IX.R.
M.D.
.4KUI WAI I(;Rt h. M.D Radiumhemmet Karolinska Hospital S 104 01 Stockholm
CRITIQUE OF “ADJUVANT RADIOTHERAPY IN OPERABLE BREAST CANCER: CORRELATION BETWEEN DOSE AND INTERNAL MAMMARY NODES AND PROGNOSES” To fhe Editor: The data presented by Strender er al.’ for the Stockholm group on the results of adjuvant radiotherapy in operable breast cancer are of great interest to the radiotherapy community. In this paper, the authors show a statistical improvement in survival for the group of patients receiving preoperative radiation followed by mastectomy, but not for those who were treated with radiotherapy following mastectomy. A rather elaborate explanation is then given, suggesting that the post-mastectomy patients may have received inadequate radiation to the internal mammary lymph nodes. However. both pre-operative and post-operative irradiation resulted in a statistically significant benefit in relapse-free survival. Since virtually all patients who have an initial relapse of their breast cancer following mastectomy will eventually die of metastatic disease, a significant improvement in relapse-free survival is bound to be reflected in the long run by significant improvement in the death rate due to breast cancer as well. Therefore, the premise that only preoperative radiotherapy improves survival will not be the case, given a long enough follow-up, if the relapse-free survival data are correct. The subseauent conclusions about
Strender. L.-E.. Wallgren. A., Arndt. J.. Amer. 0.. Bergstrom, J.. Bjonstedt, B.. Granderg. P.-O., Nitsson. B., Raf. L.. Silfversward. C.: Adjuvant radiotherapy in operable breast cancer: Correlation between dose in internal mammary nodes and prognosis. In, J Radial. Oncol. Biol. Phvs. 7:1319- 1325. 19x1.
INTERSTITIAL
PNEUMONITIS: DOSE-RATE DOSE OF RADIATION
VS TOTAL
To fhe Edifor: Interstitial pneumonitis (IPn). whether idiopathic or virus-associated, is a frequent and usually lethal complication of allogeneic bone marrow transplantation. A recent report by Keane et al.* is valuable in that it calls attention to the possibility that the total radiation dose to lung may correlate directly with fatal idiopathic IPn. Several problems with their data, however, prompted the following comments. Our chief concern has to do with the probit regression analysis which they presented in their Fig. I. The UCLA data. which they showed in