[Fractionated radiotherapy of intracranial meningiomas: 15 years' experience at the Bordeaux University Hospital Center]. / Radiothérapie fractionnée des méningiomes intracrâniens: 15 ans d'expérience au centre hospitalier universitaire de Bordeaux.

PURPOSE: To evaluate the long-term results of external fractionated radiation therapy (RT) in the treatment of intracranial meningiomas. PATIENTS AND METHODS: From January 1981 to December 1996, 156 patients with intracranial meningiomas were treated with external fractionated RT. Median age was 57. Indications for radiation therapy were as follows: (1) completely excised histologically aggressive tumors (12 patients); (2) incomplete surgical resection (37 patients); (3) medically inoperable or basilar tumors where operation would involve considerable danger or permanent neurological damage (77 patients); and, (4) tumor recurrences (30 patients). Most patients were irradiated with 6 to 9 MV photon beams. A three to four-field technique with coned-down portals was used. Since 1993, 71 patients had a three dimensional dosimetry. Doses were calculated on the 95% or 98% isodoses, all fields were treated every day, five days a week, for a median total dose of 50 Gy (1.8 Gy/Fraction). RESULTS: Median follow-up from radiation therapy was 40 months. Acute tolerance was excellent; an early clinical improvement during radiation therapy was noted in 19 patients (17.8%). Clinical improvement or stabilization was observed in 130 patients (83.4%). Radiologically, local control was obtained in 124 cases (79.4%) and tumor recurrences occurred in 21 cases (ten progressions in the treated volume, five borderline, six new locations). Overall and cause specific-survival rates were 75% and 89% at five years, and 45 and 76% at 10 years, respectively. CONCLUSION: These results reassess the role of fractionated RT in the treatment of intracranial meningiomas. Long-term tolerance is excellent for a majority of patients. The study of recurrences confirms the importance of the definition of the target volume, and asks questions about total given doses.

Fractionated radiation therapy in the treatment of intracranial meningiomas: local control, functional efficacy, and tolerance in 91 patients.

PURPOSE: To evaluate efficacy and tolerance of external fractionated radiation therapy (RT) in the treatment of intracranial meningiomas. METHODS AND MATERIALS: From January 1981 to September 1993, 91 patients with intracranial meningiomas were treated with fractionated RT. Indications were as follows: (a) incomplete surgical resection, 29 patients; (b) tumor recurrences without considering the amount of the second resection, if performed, 14 patients; (c) completely excised angioblastic, aggressive benign, and anaplastic tumors, 8 patients; (d) medically inoperable and basilar tumors where operation would involve considerable danger or permanent neurological damage, 44 patients. Most patients were irradiated with 6 to 9 MV photon beams. A three- to four-field technique with coned-down portals was used. Doses were calculated on the 95% isodose and were given 5 days a week for a median total dose of 52 Gy (1.80 Gy/fraction). RESULTS: Median follow-up from radiation therapy was 40 months. Acute tolerance was excellent, but there were six late delayed injuries. Tumor recurrences occurred in six cases. Six patients died from their tumor or RT complications, 19 from nontumoral reasons. Three, 5- and 10-year survival rates were 82, 71, and 40%, respectively. The most significant prognostic factor was age: 5-year survival rate was 86% for patients less than 65 years and 37% for patients more than 65. However, there were no differences in recurrence-free survival rates between patients younger than 65 and the oldest ones. Of 60 symptomatic patients with neurological deficits, 43 had neurological improvement (72%), beginning in some cases within 15 to 20 days after starting RT. CONCLUSION: These results reassess the role of fractionated RT in the treatment of meningiomas, and stress on its efficacy, especially on cranial nerves palsies, without severe toxicity in most cases.

[Supratentorial malignant glioma in adults. Adjustment of the treatment of 3 groups according to a clinical classification]. / Gliomes malins sus-tentoriels de l'adulte. Adaptation du traitement aux trois groupes d'une classification clinique.

Therapeutic goals cannot be the same for every patient with malignant glioma, as suggested by the study of 106 cases seen from 1975 to 1982. Seventy patients were uniformly treated by surgery, chemotherapy and radiotherapy. Two clinical parameters, i.e. age and postoperative neurological status (NS), were used to divide patients into three groups with a significantly different prognosis. Median survival was 59.5 months for group 1 (age 50 or less, good NS) and 11.5 months for group 2 (age 51 to 65 and good NS, or younger than 51 but poor NS). For group 3 (age 51 to 65 and poor NS, or older than 65), survival was six months. From 1978, two trials were carried out, with therapy being adjusted to each group. Whatever the group, surgical excision was done whenever it was consistent with preservation of the neurological status and followed by combination chemotherapy (Vincristine-VM 26-CCNU). For group 1, radiotherapy was not modified: 60 grays were delivered to the tumor and surrounding safety margin in 30 fractions over 6 weeks. Patients in group 2 received 69 grays in two daily fractions over 6 weeks (1.15 Gy each morning and evening five days a week). With this modified treatment, median survival was brought up to 20.5 months. Patients in group 3 were treated initially by surgery and chemotherapy; radiotherapy was restricted to recurrences. This policy significantly improved patients' comfort by enabling their prompt return to home. The median survival for 14 patients was 10.5 months. Our experience suggests that different therapeutic goals should be set for each group. In group 1, therapy should be aimed at obtaining prolonged survival. In group 3, survival remains short and the main concern is to improve patients' comfort. As patients in group 2 have an intermediate prognosis, they are the best candidates for therapeutic trials designed to improve the response to radiotherapy and chemotherapy.

[Probable effect of cerebral irradiation on intellectual efficiency]. / Incidence probable de l'irradiation cérébrale sur l'efficience intellectuelle.

Thirty adult patients treated for brain tumors by radiation therapy were tested by the Weschler intelligence scale (WAIS). All patients were in complete clinical and scanographic remission. Intellectual quotient (IQ) and deterioration coefficient were evaluated. This coefficient was determined by separate study of intellectual faculties according to their relationship to external aggressions. During the first six months, IQ and deterioration coefficient are similar to those observed in the normal population. From 7 to 30 months, there is a significant diminution of the intellectual faculties (p = 0,01) noted on the deterioration coefficient but without global IQ alteration. After 30 months appears a decrease in the global IQ, testifying of further alteration of intellectual faculties. Radiation therapy seems to be the predominant factor in the induction of this deterioration and the importance of the irradiation volume appears to be essential. On the other hand, neurosurgery, chemotherapy and emotional status seem to be less important. Intellectual deterioration makes professional reinsertion difficult but not impossible. Further studies are necessary to define what place take other factors like age, vascular status, tumor site, type and number of chemotherapy cycles, acute radiation tolerance, in the induction of this deterioration.

[Interest of clinical classification in prognosis and therapeutics of multiform glioblastomas of adult patients (author's transl)]. / Intérêt d'une classification clinique dans le pronostic et la stratégie thérapeutique des glioblastomes multiformes de l'adulte. A propos de cinquante-cinq cas.

Since 1978 we studied the different clinical prognostic factors on the survival of patients with malignant gliomas. The two main clinical factors of survival incidence are age and post-operative neurological status, or after anti-oedema treatment. We have established a clinical classification ; Group I : patients under 50 years with a good neurological status. Group II : Patients with one pejorative factor : age superior to 50 years, or poor neurological status. Group III : patients with two pejorative factors : age superior to 50 years and poor neurological status, or patients above 65 years. Our results confirm such an approach, by the study of 96 patients under a similar treatment. Histological grade may introduce a bias in such a study ; we have therefore studied the 55 patients whose multiform glioblastoma had an histological confirmation. This second analysis confirms the validity of our study, which is then the basis of the therapeutic approach to each group of patients.

[Response factors in the treatment of malignant gliomas in the adult (author's transl)]. / Les facteurs de réponse aux traitements des gliomes malins de l'adulte.

A statistical study was used to determine the significant prognostic factors in a protocol containing surgery, radiotherapy and polychemotherapy applied to 121 consecutive unselected patients suffering from malignant gliomas. The histological grade of the malignant tumor, the age of the patient and the neurological state if it could be evaluated after surgery appeared to be significant. It is therefore possible to suggest a clinical classification into three groups. Group 1 consists of patients aged 50 or less and a postoperative neurological state of 1 or 2 according to Order's classification; group 2 consists of patients with one pejorative factor, i.e. aged over 50 or a postoperative neurological state of 3 or 4; group 3 is those patients with two pejorative factors (aged over 50 and postoperative neurological state of 3 or 4) or aged 65 or over. Methods of application of treatment are also involved in the therapeutic response: Excision surgery appears to be essential. It improves the duration and quality of survival and influences the efficacy of combined radio-chemotherapy. By contrast, the effects of cobalt and chemotherapy must be envisaged in an efficacy/tolerance ratio which is difficult to evaluate, but for which the suggested clinical classification as a certain indicative value. Finally, the various factors lead to an approach to the concept of therapeutic responses and to determine within the total population of malignant gliomas various categories of patients in whom the profile is defined both by clinical characteristics and the tolerance of treatment and in whom different treatment techniques must be envisaged.