[The morbidity and mortality review meetings in radiotherapy departments: Procedure, implementation and prospects of the "Proust" French national project]. / Revue de morbidité et mortalité en radiothérapie : procédure, implémentation et perspectives du projet national français « Proust ¼.

Radiation-induced acute and late toxicity depends on several parameters. The type, severity and duration of morbidity are mainly related to irradiated volume, total dose and its fractionation and the intrinsic radiosensitivity of the patients. The follow-up of these toxicities is essential. However, unlike many specialties, morbidity and mortality reviews procedures are not developed as part of quality governance programs in radiation therapy departments for the monitoring of toxicity which sometimes hinder the patients' quality of life. One French survey published within the framework of the project entitled Prospective Registration of Morbidity and Mortality, Individual Radiosensitivity and Radiation Technique (Proust), conclude that there was a lack of knowledge of morbidity and mortality reviews and considerable confusion between these reviews and other quality processes without perspective for the local morbidity and mortality reviews development in a large number of the participated centers. In this article, we will discuss the procedure of the "ideal morbidity and mortality reviews" and its implementation through a monocentric experience started in 2015. Thus, the Proust project is a unique opportunity to implement and standardize a national morbidity and mortality reviews implementation in radiation therapy departments by involving the French regions.

[Hodgkin lymphoma and target definition guidelines]. / Radiothérapie « involved node ¼ et « involved site ¼ des lymphomes hodgkiniens : quels volumes cible ?

Treatment for stage I and II Hodgkin lymphoma is based on a combination of chemotherapy and radiotherapy, with a high successful cure rate. Now, the aim is to decrease toxicity rates. Positron-emission tomography scan is recommended as pretreatment baseline and is very useful to define precisely target volumes for planning radiation therapy. Based on these changes were developed guidelines for modern radiation therapy called involved node and « involved site ¼.

Complications following harvesting of patellar tendon or hamstring tendon grafts for anterior cruciate ligament reconstruction: Systematic review of literature.

Anterior cruciate ligament (ACL) reconstruction can be performed with an autograft, which is most often harvested from the patient's hamstring tendon (HT) or patellar tendon (PT). However, autograft harvesting leads to morbidity that is by no means insignificant. A systematic review of literature was performed to define the incidence of complications related to graft harvesting and the methods to prevent these complications. In March 2017, a systemic review of literature was performed using the keywords"harvesting", "harvest", "morbidity", "complication", "cruciate ligament". No time limit was applied. The studies had to be written in French or English with their abstract available online. This initial search based on the title and abstract identified 133 articles. Two independent observers analyzed each article entirely, including the references. In all, 36 articles were retained. The main complication of HT harvesting was sensory deficit because of damage to the infrapatellar branches of the saphenous nerve. This complication occurred in 39.7% to 88% of patients. This risk can be reduced by using a horizontal or oblique incision. The main complication following PT harvesting is anterior knee pain, reported in up to 46% of patients. There are substantial numbers of short-, medium- and long-term complications related to the harvesting of the two main ACL autografts. Effective means of prevention exist to reduce the risk of these complications. LEVEL OF EVIDENCE: II Systematic review of literature.

Speed-Bridge arthroscopic reinsertion of tibial eminence fracture (complementary to the adjustable button fixation technique).

In comminuted fractures of the intercondyloid eminence of the tibial spine, the quality of the reduction and the arthroscopic fixation, notably adjustable suture button fixation, is sometimes disappointing with reduction defects of the anterior bone block. In the Speed-Bridge technique, the two traction sutures of the adjustable button fixation are replaced with two braided sutures of different colors. After the button is placed above the eminence, reduction is obtained by tightening the loop of the button. The accessory communitive fragments are then packed in the depression around the main fragment. A second row provides bone suturing for these accessory fragments; traction sutures of the button are attached anteromedially and laterally with knotless anchors to obtain a Speed-Bridge-type inverted-V bone suture. The Speed-Bridge arthroscopic reinsertion technique of the tibial eminence effectively completes the adjustable button bone suture technique for communitive fractures to obtain better reduction and good stability.

Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft.

INTRODUCTION: The surgical revision rate following anterior cruciate ligament (ACL) surgery is 3% at 2 years and 4% at 5 years. Revision ACL surgery raises the question of the type of graft to be used. The present study assessed return to sports and functional results after revision ACL reconstruction by fascia lata graft. The hypothesis was that fascia lata provides a reliable graft in revision ACL surgery. MATERIAL AND METHODS: A single-center retrospective continuous study included 30 sports players with a mean age of 26.8±8 years undergoing surgical revision for iterative ACL tear between 2004 and 2013. Multi-ligament lesions were excluded. Type and level of sports activity were assessed preoperatively, after primary surgery and at end of follow-up. Clinical assessment used subjective IKDC, Lysholm and KOOS scores. RESULTS: At a mean 4.6±1.6 years' follow-up, all patients had resumed sport activity, but only 12 with the same sport at the same level. Median subjective IKDC score increased from 57 [54.3; 58.5] preoperatively to 82 [68.3; 90] at last follow-up, and Lysholm score from 46 [42.3; 51] to 90.5 [80.8; 96.8]; KOOS score at last follow-up was 94.7 [83; 100]. CONCLUSION: Functional results in revision ACL reconstruction by fascia lata graft were satisfactory, with similar return-to-sports rates as with other techniques. Fascia lata provides a reliable graft in revision ACL surgery. LEVEL OF EVIDENCE: IV, retrospective study.

Arthroscopic treatment of acute acromioclavicular dislocations using a double button device: Clinical and MRI results.

INTRODUCTION: Arthroscopic treatment of acute grade 3 and 4 acromioclavicular dislocation is controversial, due to the risk of recurrence and of postoperative reduction defect. The purpose of the present study was to investigate whether the healing of the acromioclavicular (AC) and coracoclavicular (CC) ligaments and the accurate 3D positioning parameters of the AC joint using MRI were correlated with satisfactory functional outcome. MATERIAL: Thirty-nine patients were enrolled from 2009 to 2011 and managed arthroscopically by CC lacing using a double-button device. METHODS: Clinical assessment included the Shoulder and Hand (QuickDash) score, Constant-Murley score and visual analog scale (VAS) for residual pain. Time and rate to return to work and return to sport were assessed according to type of sport and work. Postoperative complications were recorded. Radiological examination consisted of anteroposterior clavicle and lateral axillary radiographs. AC ligament healing and 3D joint congruency were assessed on MRI and correlated to the clinical results. RESULTS: Mean patient age was 35.7 years (range, 20-55). Mean follow-up was 42.3±10.6 months (range, 24-60). At final follow-up, mean QuickDash score, Constant score and VAS were respectively 1.7±4 (range, 0-11), 94.7±7.3 (range, 82-100) and 0.5±1.4 (range, 0-2). Thirty-five (90%) patients were able to resume work, including heavy manual labor, and sport. Radiology found accurate 3D joint congruency in 34 patients (87%) and CC and AC ligament healing in 36 (93%). Complications included reduction loss at 6 weeks in 3 patients, requiring surgical stabilization. Satisfactory functional results were associated with accurate AC joint congruency in the coronal and axial planes (P<0.05) and good AC and CC ligament healing (P<0.04). An initial 25% reduction defect in the coronal plane was not associated with poor functional results (P=0.07). CONCLUSION: Arthroscopic treatment by CC lacing satisfactorily restored ligament and joint anatomy in the present series. These satisfactory anatomic results correlated with good clinical outcome encourage continuing with this technique. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Iliac Crest Avulsion Fracture in a Young Sprinter.

Avulsion fracture of the iliac crest is an uncommon pathology. It usually occurs in teenagers during sport activities, more common in boys. We report a case of 16-year-old male competitive sprinter, who had an avulsion of a part of the iliac crest and the anterior-superior iliac spine during a competition. The traumatism occurred during the period of acceleration phase out of the blocks which corresponds to the maximum traction phase on the tendons. Then a total loss of function of the lower limb appears forcing him to stop the run. X-ray and CT scan confirmed the rare diagnosis of avulsion of the quasitotality of the iliac crest apophysis, corresponding to Salter 2 fracture. We performed an open reduction and internal fixation with two screws, allowing a return to sport after 3 months and his personal best record in the 100 meters at the 6th postoperative month.

Bartonella henselae osteoarthritis of the upper cervical spine in a 14-year-old boy.

We report a case of Bartonella henselae, an agent of cat scratch disease, C1-C2 osteoarthritis with osteolysis of the lateral mass of C2 in a 14-year-old boy. Oral antibiotics did not successfully treat the infection and surgery was necessary to treat the septic arthritis. The case opens discussion about bacterial osteoarthritis of the cervical spine and bone involvement in disseminated bartonellosis.

Solid aneurysmal bone cyst on the cervical spine of a young child.

INTRODUCTION: Solid aneurysmal bone cyst (S-ABC) is a variant of aneurysmal bone cyst (ABC), an uncommon benign bone tumor. There are few cases described in the cervical spine in kids up today. We treated a recurrent case with neurological involvement that needed multiple surgical procedures and radiotherapy. CASE PRESENTATION: We report a case of C4 located S-ABC concerning a 2-year-old boy treated surgically by anterior and posterior approach. Three months after the initial procedure appearance of a tetraparesis led to diagnose a local recurrence treated by sclerotherapy and a second surgery. The patient had a full neurological recovery. Three months later, a follow-up CT scan showed a second recurrence requiring a new surgical revision by anterior approach and radiotherapy. OUTCOME: At 6-year follow-up after four surgical procedures, sclerotherapy and radiotherapy, the aneurysmal bone cyst has been healed. Patient had neurological impairment after a local recurrence but had full recovered after final revision surgery.

[Posteromedial dislocation of the elbow with lateral condyle and coronoid process fractures: a case report]. / Luxation postéro-médiale du coude associée à une fracture du condyle latéral et du processus coronoïde chez un adolescent : à propos d'un cas.

We report the occurrence of a rare injury in a teenager not yet described in the literature: the association of posteromedial elbow dislocation, lateral condyle and coronoid process fractures. The treatment required fixation of lateral condyle and coronoid process thanks to lateral and medial approaches and capsular fixation. This lesion is unstable, such as the terrible triad described in adults. It requires external and anterior stabilization of the elbow. The management of such injuries of the elbow is complex. It must consider both bone and ligament instability, and risk of injury to growth plates.

Local recurrence after ductal carcinoma in situ breast conserving treatment. Analysis of 195 cases.

PURPOSE: Ductal carcinoma in situ overall prognosis is excellent, but after breast conserving surgery, with or without radiotherapy, local recurrences can lead to locoregional or distant evolution and death. However, there are few data on optimal local recurrences treatment and long-term impact on survival. PATIENTS AND METHODS: This study included 195 women treated from 1985 to 1996 by conservative surgery (CS) or conservative surgery followed by radiotherapy (CS+RT), presenting local recurrences, with a 156-month median follow-up. RESULTS: Eighty-two out of 195 (42%) local recurrences were non-invasive (in situ) and 113 (58%) invasive. In situ local recurrence was discovered by mammography in 80.5% of the cases versus 47.5% for invasive local recurrence (P=0.0001). Salvage mastectomy was used in 53% of the cases after conservative surgery and 75% after conservative surgery followed by radiotherapy. The axillary nodal involvement rates were 11.8% and 25.8% among 17 and 62 patients with in situ and invasive local recurrences. Among 113 patients with invasive local recurrences and 82 with in situ local recurrences, 19 (16.8%) and three (3.6%) developed metastases, respectively. Among invasive local recurrences, comedocarcinoma subtype was highly predictive of subsequent metastases (32% versus 4.4%, P<0.0007). CONCLUSION: Invasive local recurrence after ductal carcinoma in situ treatment could be a dramatic event, fully changing long-term prognosis. Early mammographic local recurrence diagnosis (if possible still at non-invasive stage) seems essential to avoid or minimize metastatic risk. Mastectomy remains the safest option but, in some cases, a new conservative approach could be discussed.

Ductal carcinoma in situ of the breast in younger women: a subgroup of patients at high risk.

BACKGROUND: After breast conservative treatment (BCT), young age is a predictive factor for recurrence in patients with Ductal Carcinoma In Situ (DCIS) of the breast. The purpose of this study was to evaluate predictive factors for recurrence and outcomes in these younger women (under 40 years) treated for pure DCIS. METHODS: From 1974 to 2003, 207 cases were collected in 12 French Cancer Centers. Median age was 36.3 years and median follow-up 160 months. Seventy four (35.8%) underwent mastectomy, 67 (32.4%) lumpectomy alone and 66 (31.9%) lumpectomy plus radiotherapy. RESULTS: 37 recurrences occurred (17.8%): 14 (38%) were in situ and 23 (62%) invasive. After BCT, the overall rate of recurrence was 27% (33% in the lumpectomy plus radiotherapy group vs. 21% in the lumpectomy alone group). Comedocarcinoma subtype (p = 0.004), histological size more than 10 mm (p = 0.011), necrosis (p = 0.022) and positive margin status (p = 0.019) were statistically significant predictive factors for recurrence. The actuarial 15-year rates of local recurrence were 29%, 42% and 37% in the lumpectomy alone, lumpectomy and whole breast radiotherapy and lumpectomy + whole breast radiotherapy with additional boost groups respectively. After recurrence, the 10-year overall survival rate was 67.2%. CONCLUSION: High recurrence rates (mainly invasive) after BCT in young women with DCIS are confirmed. BCT in this subgroup of patients is possible if clear and large margins are obtained, tumor size is under 11 mm and necrosis- and/or comedocarcinoma-free.

Graded changes in balancing behavior as a function of visual acuity.

In a dynamic postural task, visual information plays a fundamental role in the selection of the balancing strategy. While standing on a platform oscillating in the antero-posterior direction, subjects almost fix their head in space when vision is allowed and oscillate with the platform with eyes closed. We investigated two competing hypotheses regarding the relationship between visual acuity and balance control strategy. One hypothesis refers to the existence of a threshold value of visual acuity as a turning point between the eyes-open and eyes-closed strategy. The other assumes that the change from eyes-open to eyes-closed behavior is continuous and parallels the progressive worsening of visual acuity. Ten subjects balanced on the mobile platform wearing an examination frame and a facemask occluding peripheral vision. Seven different test lenses were used in different trials to modify visual acuity, from a visus value of 10/10 to severely blurred vision. Head stabilization in space progressively worsened with the decrease in visual acuity and turned toward the eyes-closed behavior when vision was blurred. The increase in head oscillation as a function of visual acuity was best fitted by a logarithmic function. In five of the subjects, additional trials were performed without facemask, to add peripheral vision to each visual acuity level, and with black lenses to allow peripheral vision alone. Addition of peripheral vision gave a significant contribution to head stabilization. With peripheral vision alone, head stabilization was intermediate between the eyes-closed and 10/10 visus value condition. We conclude that, in order to stabilize the head in space, visual information of the environment must be definite and worsening of central vision leads to a graded modification of the 'head fixed in space' behavior. Thus, the more conservative hypothesis of two different fundamental balancing strategies is not supported. Instead, the body exhibits a continuous mode of balancing patterns as a function of visual acuity. The findings support the notion that the central mechanism for head stabilization operates through linear integration of the central-field visual input with the general somesthetic feedback.

Contribution of surgery in patients with bulky residual disease after chemoradiation for advanced cervical carcinoma.

AIM: To report the outcome of 30 patients who underwent surgery after concomitant chemoradiation for locally advanced cervical cancer with residual disease > or = 2 cm. METHODS: From 1988 to 2004, 143 patients with FIGO stage IB2-IVA cervical cancer underwent surgery after concurrent chemoradiotherapy. Among them, 30 had a residual cervical tumour > or = 2 cm prior to surgery. Surgery consisted in a simple or radical hysterectomy (n=15) or in a pelvic exenteration (n=15). Endpoints were recurrence and distant metastasis rates, overall survival (OS) and disease-free survival (DFS) at 3 and 5 years. Analysis included FIGO stage, response to chemoradiation, para-aortic lymphatic status or type of surgery: palliative (remaining disease after surgery) or curative (no evidence of remaining disease after surgery). RESULTS: Surgery has been only palliative in 11 cases. Pelvic recurrences occurred in 8 patients after a median interval of 8.8 months. Distant metastases occurred in 8 patients after a median interval of 13 months. So far, 16 patients have died (53.3%). The 3-year and 5-year OS rates are 64.9% and 55.6%, respectively, for the 19 patients who had a curative surgery. The DFS rate is 50.8% at 3 and 5 years in this latter group. Overall 12 patients (40%) are alive and free of disease after a median follow-up of 32.5 months. CONCLUSIONS: Adjuvant surgery may improve the outcome of patients with bulky residual tumour after chemoradiation for locally advanced cervical cancer, allowing a 5-year OS of 55.6% after curative intervention.

[Ductal carcinoma in situ of the breast. Analysis of 882 cases]. / Carcinome canalaire in situ du sein. Analyse de 882 cas.

OBJECTIVE: This study assesses the results of "current clinical practice" among 882 women treated in nine French Cancer Centers from 1985 to 1995 for pure ductal carcinoma in situ (DCIS) of the breast. METHOD: Median age was 53 years (range 21-87); 177 (20%) patients underwent mastectomy (M), 190 (22%) conservative surgery alone (CS) and 515 (58%) conservative surgery with radiotherapy (CS + RT). RESULTS: The crude 7-year local relapse (LR) rates were 2%, 31% and 13% among the M, CS and CS+RT subgroups (p<0.0001). All four LR after M were invasive as well as 31 (52%) out of 59 and 40 (61%) out of 66 in the CS and CS+RT groups. Distant metastases occurred in 1%, 3% and 1% of the three treatment groups. No LR factors were found in the M group. Among women treated with CS, the 7-year LR rates were 36%, 31% and 30% among women aged 40 or less, 41 to 60 and 61 or more (NS). For women treated by CS+RT, the LR rates in these age subgroups were 33%, 13% and 8%, respectively (p<0.0001). Patients with negative, positive or uncertain margins had 7-year LR rates of 26%, 56% and 29% respectively if treated with CS (p=0.02) and 11%, 23% and 9% if treated with CS+RT (p=0.0008). RT reduced LR rates by 65% in all histological subgroups, but more particularly in comedocarcinoma and mixed cribriform/papillary subgroups. The 7-year rate of contralateral breast cancer was 7%, identical in all subgroups. CONCLUSION: Mastectomy remains the safest treatment for women with DCIS, with a 98% 7-year control rate. After conservative surgery, RT reduces very significantly LR rates, according to the NSABP B-17 and EORTC 10853 randomized trial results. The RT benefit is present in all clinical/histological subgroups, but its magnitude varies. Young age (<40 years) and incomplete excision are the most important LR risk factors.

[Multicenter study on dose escalation with conformal and conventional radiotherapy for the treatment of localized prostatic cancer. Preliminary results of tolerance and quality of life]. / Etude multicentrique d'escalade de dose par radiothérapie conformationnelle pour le traitement du cancer localisé de la prostate. Résultats préliminaires de la tolérance et de la qualité de vie.

OBJECTIVE: To study the safety of conformal radiotherapy dose escalation up to 80 Gy for curative treatment of prostate cancer. MATERIAL AND METHODS: A multicentre trial sponsored by the PHRC include 164 patients under the age of 75 years with stage T1b-T3 N0 M0 prostatic adenocarcinoma, between 1995 and 1998. The prostate was treated at 5 dose levels: 18 patients at 66 Gy, 28 at 70 Gy, 49 at 74 Gy, 48 at 78 Gy, 21 at 80 Gy. The acute and delayed toxicity was graded according to a multidisciplinary glossary. Quality of life was evaluated before and one year after treatment using the EORTC QLQ-C30 questionnaire and additional questions. RESULTS: 89% and 55% of mild or moderate gastrointestinal and urinary adverse effects were observed during treatment, respectively. At long-term follow-up, of the 162 evaluable patients, 12.3% presented grade 2 adverse effects and 2.5% presented grade 3 adverse effects (1 case of haematuria, 2 urethral strictures, 1 bladder neck lesion) with no significant difference between the various dose levels. Two successive quality of life questionnaires were available for 119 patients: tiredness, pain and dyspnoea increased in parallel, but non-significantly in the groups receiving conventional doses or high doses. The proportion of patients reporting sexual activity without endocrine therapy decreased from 48% before treatment to 35% one year later. The proportion of patients with no clinical or laboratory signs of progression was higher in the high-dose group. CONCLUSION: No significant difference was observed between conventional dose levels and high dose levels in terms of toxicity or quality of life. As the adverse effects were acceptable, a randomized trial comparing 70 Gy and 80 Gy has been initiated.

Combined brachytherapy and surgery for early carcinoma of the uterine cervix: analysis of extent of surgery on outcome.

PURPOSE: The aim of this retrospective study was to evaluate the survival data and rates and patterns of complications and recurrences for patients who had early uterine cervix carcinoma and underwent brachytherapy and subsequent surgery. METHODS AND MATERIALS: Between January 1990 and December 1997, 192 women with cervical carcinoma (Stages IA2 with vascular invasion [n = 28], IB1 [n = 144], and IIA [n = 20]) underwent brachytherapy, delivering 60 Gy and then hysterectomy with external iliac lymphadenectomy. Piver class I, II, and III hysterectomies were performed on 136, 38, and 18 patients, respectively. Adjuvant chemoradiotherapy was delivered to patients with positive lymph nodes. RESULTS: The median follow-up time was 61 months. After brachytherapy, a pathologically complete response (CR) was observed in 137 (71.3%) of 192 women. The distribution of CRs according to tumor stage was as follows: Stage IA2, 24 (85.7%) of 28; Stage IB1, 105 (72.9%) of 144; and Stage IIA, 8 (40%) of 20. Patients with Stage IB1 cancer had 13 lymph node metastases (9%), as did 6 with Stage IIA disease (30%). Pelvic recurrences occurred in 9 (4.6%) of the 192 patients; in 3, local relapses were associated with relapses at distant sites. Ten patients had systemic relapses (5.2%). Recurrences at distant sites were more frequent (p < 0.02) in partial responders, and other recurrences were more frequent in patients with lymph node metastases (p < 0.04). The overall 5-year disease-free survival rate was 91.2% (96.2% for Stage IA2, 91% for Stage IB1, and 84.4% for Stage IIA cancers). The class of hysterectomy did not influence the outcome. Late complications occurred in 28 patients (Grade 1, 24 [12.5%]; Grade 2, 4 [2%]; and Grade 3, 1 [0.5%] of 192 patients). CONCLUSIONS: Combined treatments resulted in high local control and low morbidity rates in patients with early-stage cervical carcinoma. Limited surgery seemed to be adequate after intracavitary therapy.

Dose escalation with 3D-CRT in prostate cancer: French study of dose escalation with conformal 3D radiotherapy in prostate cancer-preliminary results.

PURPOSE: To evaluate the feasibility of dose escalation in a multi-institutional study in prostate cancer patients. METHODS AND MATERIALS: Between October 1995 and October 1998, 164 patients with localized adenocarcinoma of the prostate were treated with 3-dimensional conformal radiotherapy at one of five French institutions. The dose of radiation was escalated from 66 to 80 Gy (ICRU point). The maximum dose to the rectal wall was limited to 75 Gy. RESULTS: Results were compared in two groups, one (group 1) receiving the standard dose (n = 46 patients; 66 to 70 Gy) and the other (group 2) receiving the escalated dose (n = 118 patients; 74 to 80 Gy). There was no difference in the characteristics of patients between the two groups. The mean follow-up time was 32 months in group 1 and 17.5 months in group 2. No statistical difference between the two groups was observed in the incidence of late gastrointestinal and urinary toxicities. The probability of achieving a posttreatment prostate-specific antigen nadir of

[Radiochemotherapy of uterine cervix cancers. Recent data]. / Radiochimiothérapie des cancers du col utérin. Données récentes.

Low-stage uterine cervix carcinoma can be treated by either surgery, radiation therapy or combined treatments with high cure rates ranging from 90 to 95% for stage IB1 tumors. However, the standard treatment, combining external beam plus intracavitary radiation, fails to control the progression of the disease in 35 to 90% of patients with locally advanced cervical cancer. No substantial improvements have been made in the treatment of these tumors in the past two decades. The addition of concurrent 5-FU in a phase III study failed to improve the results in the overall patient population, but the five-year DFS was significantly better in a subset of patients (tumor > 5 cm and IB/IIA or medial parametrial IIB disease). Concurrent chemoradiation and adjuvant chemotherapy with epirubicin showed, in a phase III study, a significantly longer DFS in patients treated with chemotherapy despite the same long-term local tumor control. After many phase II studies, five phase III studies have recently demonstrated a 40 to 60% reduction in the relative risk of recurrence with cisplatin-containing chemoradiation. Across these studies, the risk of death was reduced by 30 to 50%. The benefit was less clear in patients with stages III-IV tumors than in patients with lower stages associated with poor prognostic factors. Haematologic and gastrointestinal toxicity of chemoradiation was greater than that of radiotherapy alone. However, late side effects were similar in the different treatment groups. These results must be confirmed with a longer follow-up. The importance of concurrent chemotherapy during the brachytherapy procedure should be analyzed. It has yet to be determined which chemotherapy regimen achieves the most favorable therapeutic ratio.

Safety and efficacy of splenic irradiation in the treatment of patients with idiopathic myelofibrosis: a report on 15 patients.

Splenic irradiation in idiopathic myelofibrosis (IMF) has often been use d in selected situations when other therapies were unefficient or contraindicated. This could improve quality of life of patients, but literature remains rare in this field. We have assessed the impact of splenic irradiation in 15 patients with IMF. All of them were no longer responsive to usual treatments, and they presented at least one of the following features: constitutional symptoms, splenic pain, large splenic size, and anemia requiring >2 units of red blood cell transfusion per month. The planned schedule of radiotherapy consisted in daily fractions of 0.4-1 Gy. The median dose of radiotherapy per treatment was 9.8 Gy (range, 0.6-30.5). The overall response rate was 59% with a median duration of 10 months (range, 1-19). Splenic irradiation was more effective on constitutional symptoms, splenic pain, and spleen size. The best responses were noted when full doses of radiotherapy could be delivered, and when patients were previously fewly transfused. Splenic irradiation effectively palliates IMF-related symptoms, and constitute an alternative therapy for patients refractory to usual treatments.