Hypofractionated Stereotactic Radiotherapy for Patients with Intracranial Meningiomas: impact of radiotherapy regimen on local control.

We evaluated efficacy and tolerance of hypofractionated stereotactic radiation treatment (hFSRT) in the management of intracranial meningiomas. Between December 2008 and June 2016, 126 patients with 136 intracranial meningiomas were treated with robotic hFSRT. hFSRT was performed as primary irradiation and as a salvage option for the local recurrence after prior radiotherapy. The median prescription dose was 25 Gy (12-40) with a median number of fractions of 5 (3-10). After a median follow-up of 20.3 months (range 1-77 months), the 24-months local control (LC) rate was 81% in the primary hFSRT group and 39% after hFSRT in the re-irradiation group (p=0.002). The clinical control rate of symptoms in the overall population was 95% (95% CI: 89-98%). Progression-free survival (PFS) in the overall population at 24 months was 70% (95% CI: 60%-79%). In the primary hFSRT group, PFS was significantly lower with the most hypofractionated schedules of 21-23 Gy in 3 fractions vs. 25-40 Gy in 5-10 fractions: 62% vs. 92% (p = 0.0006). The incidence of radionecrosis at 24 months was significantly lower in the primary hFSRT group, at 2% vs. 20% in the re-irradiation hFSRT group (p = 0.002).

[Brachytherapy for head and neck cancers]. / Curiethérapie des cancers de la tête et du cou : synthèse des recommandations européennes et principales indications.

The main indications of the brachytherapy of head and neck cancers are the limited tumours of the lip, the nose, the oral cavity and the oropharynx. Nasopharynx tumours are nowadays treated by intensity-modulated radiotherapy. This technique can be exclusive, associated with external radiotherapy or postoperative. It can also be a salvage treatment for the second primaries in previously irradiated areas. If the low dose rate brachytherapy rules remain the reference, the pulse dose rate technique allows the prescription of the dose rate and the optimisation of the dose distribution. Results of high dose rate brachytherapy are now published. This paper reports the recommendations of the Gec-ESTRO, published in 2017, and takes into account the data of the historical low dose rate series, and is upgraded with the pulsed-dose rate and high dose rate series.

Low-dose brachytherapy for early stage penile cancer: a 20-year single-institution study (73 patients).

PURPOSE/OBJECTIVES: The aim of this study is to analyze the results of exclusive interstitial brachytherapy (IBT) as a conservative approach in the treatment of penile cancer confined to the glans or the shaft with long-term follow-up in a single institution. MATERIALS/METHODS: Between July 1992 and November 2013, 73 consecutive patients with non-metastatic invasive penile cancer were treated by Low dose rate (LDR) IBT in our institution. The localization of the primary lesion was glands in 67 patients (91.8 %) and shaft in 6 patients (8.2 %). All 73 patients presented with squamous cell carcinoma with grades of differentiation as follows: 34 patients with grade 1 (44.7 %), 9 patients with grade 2 (11.8 %), 9 patients with grade 3 (11.8 %) and 21 patients unknown (28.8 %). Six patients (7.8 %) presented with in situ carcinoma, 55 patients (75,3 %) presented with T1, 11 patients (15 %) presented with T2, and one patient (1.3 %) presented with Tx. Inguinal nodal dissection was performed in 29 patients (38.2 %); 13 patients (17.8 %) presented with histologically confirmed positive ganglion. After circumcision, IBT was performed using a hypodermic needle. The median dose delivered was 60 Gy (range, 40 to 70 Gy). The median activity of the iridium-192 wire was 1.12 mCi/cm, and the median reference isodose rate was 0.4 Gy/h (range, 0.2-1.2). Patients with histological inguinal metastases received external beam radiotherapy to the selected inguinal affected area with a median dose of 45 Gy (30-55 Gy). RESULTS: The median follow-up time was 51.8 months (range 34.4 to 68.7). The 5-year overall survival was 82.0 %, with eight deaths from cancer and five non-cancer-related deaths. Disease-specific survival was 91.4 %, relapse-free survival was 64.4 %, and local relapse-free survival as 74 %. Total or partial penile preservation was 87.9 % at 5-years. Complications rates at 5 years were 6.6 % urethral stenosis (five patients), two patients (2.6 %) with pain related to sexual intercourse and four patients (5.3 %) with dysuria grade 2. Five patients (6.8 %) required penile amputation for necrosis. CONCLUSIONS: IBT provides good local control with organ preservation, excellent tolerance and low complication rates in early-stage penile cancers.

Toxicity and efficacy of cetuximab associated with several modalities of IMRT for locally advanced head and neck cancer.

PURPOSE: Intensity-modulated radiation therapy (IMRT) has shown its interest for head and neck cancer treatment. In parallel, cetuximab has demonstrated its superiority against exclusive radiotherapy. The objective of this study was to assess the acute toxicity, local control and overall survival of cetuximab associated with different IMRT modalities compared to platinum-based chemotherapy and IMRT in the ARTORL study (NCT02024035). PATIENTS AND METHOD: This prospective, multicenter study included patients with epidermoid or undifferentiated nasopharyngeal carcinoma, epidermoid carcinoma of oropharynx and oral cavity (T1-T4, M0, N0-N3). Acute toxicity, local control and overall survival were compared between groups (patients receiving cetuximab or not). Propensity score analysis at the ratio 1:1 was undertaken in an effort to adjust for potential bias between groups due to non-randomization. RESULTS: From the 180 patients included in the ARTORL study, 29 patients receiving cetuximab and 29 patients treated without cetuximab were matched for the analysis. Ten patients (34.5%) reported acute dermal toxicity of grade 3 in the cetuximab group versus three (10.3%) in the non-cetuximab group obtained after matching (P=0.0275). Cetuximab was not significantly associated with more grade 3 mucositis (P=0.2563). There were no significant differences in cutaneous or oral toxicity for patients treated with cetuximab between the different IMRT modalities (P=1.000 and P=0.5731, respectively). There was no significant difference in local relapse-free survival (P=0.0920) or overall survival (P=0.4575) between patients treated with or without cetuximab. CONCLUSION: Patients treated with cetuximab had more cutaneous toxicities, but oral toxicity was similar between groups. The different IMRT modalities did not induce different toxicity profiles.

[Brachytherapy for head and neck cancers]. / Curiethérapie des cancers des voies aérodigestives supérieures.

The main indications of brachytherapy for head and neck cancers are limited tumours of the oral cavity, the oropharynx and the nasopharynx. This technique can be exclusive, associated with external radiotherapy or postoperative. This is also a treatment for second localizations in previously irradiated areas. If low-dose rate brachytherapy is the reference, the pulse dose rate brachytherapy by control of the dose rate and optimisation of the dose distribution is the technique to be preferred. High-dose rate brachytherapy is an option. The major prognosis factors of local control and complications are the use of a leaded protection of the mandible, the intersource spacing (1.2-1.4 cm), the volume treated (30 cm(3), i.e. three loops), the safety margin (5 mm), the dose rate (0.5 Gy/h), the total dose (65 Gy in case of exclusive brachytherapy, 25 Gy in case of a combination of external beam irradiation [50 Gy] and brachytherapy in the oropharyngeal carcinomas, 35 Gy in case of a combination of external beam irradiation [40 Gy] and brachytherapy in the oral cavity carcinomas, 60 Gy in case of a second localization in previous irradiated tissues), the delay between external irradiation and brachytherapy (<20 days), the dose per fraction and the treated volume for high-dose rate brachytherapy. Brachytherapy, when possible, is the optimal method of irradiation of head and neck carcinomas with limited volume.

[Experience feed back committee in radiotherapy (CREx): a compulsory tool for security management evaluation at two years]. / La cellule de retour d'expérience (CREx) en radiothérapie: un outil indispensable au management de la sécurité. Une évaluation après deux ans d'activité au centre Oscar-Lambret.

After working on treatment organisation in radiotherapy (bonne pratiques organisationnelles en radiothérapie - action pilote MEAH 2003), the development of a security policy has become crucial. With the help of Air France Consulting and the MEAH, three cancer centers in Angers, Lille and Villejuif worked together on the implantation of experience feed back committees (CREx) dedicated to the registration, analysis and correction of precursor events. After two years, we report the centre Oscar-Lambret experience in Lille and try to get the recommendations for generalisation of the process. This seems now to be compulsory for security management in oncology.

Head and neck squamous cell carcinoma in elderly patients: a long-term retrospective review of 273 cases.

BACKGROUND: The prolongation of life expectancy results in an increasing number of malignant neoplasms occurring in the elderly population. For a long time these patients were not considered good candidates to receive aggressive therapy and probably were inadequately treated in many instances. OBJECTIVE: To assess the outcome of patients older than 74 years who had had head and neck squamous cell carcinoma. MATERIALS AND METHODS: In our database of 4610 consecutive patients with head and neck squamous cell carcinomas who were evaluated and treated at the Centre Oscar Lambret, Northern France Comprehensive Cancer Center, Lille, over a 10-year period (1974-1983), we identified 273 patients who were 75 years or older. The outcome was updated for all patients included in the database. RESULTS: A significantly higher proportion of females were noted in the older patient group (43/273, 15.8%) than in younger patient group (192/4337, 4.4%, P<.001). There were no differences for primary site except for hypopharyngeal squamous cell carcinoma that occurred less frequently in the elderly patients (8.8% vs 14.5%, borderline significance P =.02). There were no differences for TNM stage grouping, histological classification, incidences of previous cancer, and comorbidities. Surgery was performed in a smaller proportion of older patients (13.9% vs 27.4%, P<.001, for the primary site and 15.4% vs 35.6%, P<.001, for those occurring in the neck) as well as chemotherapy that was delivered in 5.5% vs 17.7% (P<.001). On the contrary, there was no difference in radiotherapeutic treatments. Tolerance to treatment was similar and there was the same proportion of persistent diseases 2 months after completion of the overall treatment (27.8% vs 25.4%, P =.94). Pooling local, regional, and distant failures and metachronous cancers, there was a borderline lower incidence in older patients (57.1% vs 64.2%, P =.02), which is explained by an obvious shorter life expectancy. If survival is not meaningful in such a comparison (5-year survival 23.8% vs 36.4%), then the causes of deaths may be compared. Among the 4067 patients who were dead at the last update, index tumor evolution-related deaths numbered 130 (48.1% of dead patients in this cohort) in older patients compared with 2045 (53.9% of dead patients in this cohort), which was not significantly different. There was no difference in treatment-related deaths (11.1% vs 9.3%). Fewer intercurrent disease-related deaths occurred in the older patients (19.7% vs 11.8%). CONCLUSIONS: Head and neck squamous cell carcinoma in elderly patients did not seem to have a significantly different outcome when compared with head and neck squamous cell carcinoma occurring in younger patients. When properly monitored, conventional therapies seem feasible in older patients.

[Comparison of conventional and conformational dosimetry in radiotherapy of cerebral neoplasms]. / Comparaison entre dosimétries classique et conformationnelle dans l'irradiation de tumeurs cérébrales.

PURPOSE: We prospectively compared a conventional treatment planning (PT2D) and 3-dimensional conformal treatment planning (PT3D) for radiotherapy of cerebral tumours. PATIENTS AND METHODS: Patients treated between 1/10/98 and 1/4/99 by irradiation for cerebral tumours were analysed. For each case, we planned PT2D using conventional orthogonal x-ray films, and afterward, PT3D using CT scan. Gross tumor volume, planning target volume and normal tissue volumes were defined. Dose was prescribed according to report 50 of the International Commission on Radiation Units and Measurements (ICRU). We compared surfaces of sagittal view targets defined on PT2D and PT3D and called them S2D and S3D, respectively. Irradiated volumes by 90% isodoses (VE-90%) and normal tissue volumes irradiated by 20, 50, 90% isodoses were calculated and compared using Student's paired t-test. RESULTS: There was a concordance of 84% of target surfaces defined on PT2D and PT3D. Percentages of target surface under- or-over defined by PT2D were 16 and 13% respectively. VE-90% was decreased by 15% (p = 0.07) with PT3D. Normal brain volume irradiated by 90% isodose was decreased by 27% with PT3D (p = 0.04). CONCLUSION: For radiotherapy of cerebral tumors using only coplanar beams, PT3D leads to a reduction of normal brain tissue irradiated. We recommend PT3D for radiotherapy of cerebral tumors, particularly for low-grade or benign tumors (meningiomas, neuromas, etc.).

Post-radiation severe xerostomia relieved by pilocarpine: a prospective French cooperative study.

BACKGROUND AND PURPOSE: The aim of the study was: (1) to confirm the action of pilocarpine hydrochloride (Salagen) against xerostomia: (2) to correlate the response to dose/volume radiotherapy parameters. MATERIALS AND METHODS: From June 1995 to February 1996, 156 patients with severe radiation induced xerostomia received pilocarpine hydrochloride orally. IS mg per day with a 5 mg optional increase at S weeks up to a daily dose of 25 mg beyond 9 weeks. RESULTS: One hundred and forty five patients are fully evaluable. Treatment compliance was 75%. Thirty eight patients (26%) stopped treatment before week 12 for acute intolerance (sweating, nausea, vomiting) or no response. No severe complication occurred. Ninety ses en patients (67%) reported a significant relief of symptoms of xerostomia at 12 weeks. Within 12 weeks, the size of the subgroup ith normal food intake almost doubled (13-24 patients) while the size of the subgroup with (nearly) impossible solid food ingestion decreased by 38% (47 vs. 29 patients). The impact on quality of life was considered important or very important by 77% of the responders. CONCLUSIONS: No difference was found according to dose/volume radiotherapy parameters suggesting that oral pilocarpine hydrochloride: (1) acts primarily by stimulating minor salivary glands: (2) can be of benefit to patients suffering of severe xerostomia regardless of radiotherapy dose/volume parameters: (3) all responders are identified at 12 weeks.

[Use of fast neutrons in the treatment of tumors of the salivary glands: rationale, review of the literature and experience in Orleans]. / Utilisation des neutrons rapides dans le traitement des tumeurs des glandes salivaires: rationnel, revue de la littérature et expérience d'Orléans.

If low LET radiation therapy (photons, electrons), following radical microscopically and complete surgery can improve results in term of local control from 34 to 74% for salivary gland tumors, local control is more difficult to achieve in advanced tumors and only palliative treatment is usually attempted. In this survey, all the patient series treated worldwide were reviewed. They show an overall control rate of 31% with photon vs 64% with neutron therapy. A prospective randomised trial sponsored by the RTOG and the MRC published in 1988 and reviewed in 1993 showed an overall locoregional complete tumor clearance of 67% for neutrons and 17% for photons (P < 0.005), with 68% and 25% survival at two years for neutrons and photons respectively. This study was closed for ethical reasons. In Orleans, since 1987, 59 patients have been treated. At five years the persistent local control probability was 69.5%, the five-year crude survival probability 66% and the five-year tumor free survival probability was 64.5%. This review provides evidence that surgical treatment for salivary gland tumors should be limited to patients presenting a high likelihood of negative surgical margin and a small risk of facial nerve damage. Others patients should receive neutron radiation therapy alone as definitive treatment.

Randomized trial of neoadjuvant chemotherapy in oropharyngeal carcinoma. French Groupe d'Etude des Tumeurs de la Tête et du Cou (GETTEC).

The objective of the study was to evaluate the effect of neoadjuvant chemotherapy on the survival of patients with oropharyngeal cancer. Patients with a squamous cell carcinoma of the oropharynx for whom curative radiotherapy or surgery was considered feasible were entered in a multicentric randomized trial comparing neoadjuvant chemotherapy followed by loco-regional treatment to the same loco-regional treatment without chemotherapy. The loco-regional treatment consisted either of surgery plus plus radiotherapy or of radiotherapy alone. Three cycles of chemotherapy consisting of Cisplatin (100 mg/m2) on day 1 followed by a 24-hour i.v. infusion of fluorouracil (1000 mg/m2/day) for 5 days were delivered every 21 days. 2-3 weeks after the end of chemotherapy, local treatment was performed. The trial was conducted by the Groupe d'Etude des Tumeurs de la Tête Et du Cou (GETTEC). A total of 318 patients were enrolled in the study between 1986 and 1992. Overall survival was significantly better (P = 0.03) in the neoadjuvant chemotherapy group than in the control group, with a median survival of 5.1 years versus 3.3 years in the no chemotherapy group. The effect of neoadjuvant chemotherapy on event-free survival was smaller and of borderline significance (P = 0.11). Stratification of the results on the type of local treatment, surgery plus radiotherapy or radiotherapy alone, did not reveal any heterogeneity in the effect of chemotherapy.

Concomitant b.i.d. radiotherapy and chemotherapy with cisplatin and 5-fluorouracil in unresectable squamous-cell carcinoma of the pharynx: clinical and pharmacological data of a French multicenter phase II study.

PURPOSE: The aim of this phase II study conducted on unresectable squamous cell carcinoma (USCC) of the oro- and hypopharynx was to associate twice-a-day (b.i.d.) continuous nonaccelerated radiotherapy with concomitant cisplatin (CP)-5-fluorouracil (5-FU) chemotherapy, both given at full dose. Feasibility, efficacy, survival, and pharmacokinetic-pharmacodynamic relationships were analyzed. METHODS AND MATERIALS: Fifty-four consecutive patients with strictly USCC of oro- and/or hypopharynx received continuous b.i.d. radiotherapy (RT) (2 daily fractions of 1.2 Gy, 5 days a week, with a 6-h minimal interval between fractions). Total RT dose was 80.4 Gy on the oropharynx and 75.6 Gy on the hypopharynx. Three chemotherapy (CT) courses of CP-5-FU were given during RT at 21-day intervals (third not delivered after the end of RT). CP dose was 100 mg/m2 (day 1) and 5-FU was given as 5-day continuous infusion (day 2-day 6: 750 mg/m2/day cycle 1, 750 mg total dose/day cycle 2 and 3). Pharmacokinetics was performed for 5-FU (105 h follow-up) and CP (single sample at 16 h). Special attention was paid to supportive care. RESULTS: Good feasibility of RT was observed (85.2% of patients with total dose > 75 Gy). Five patients received 1 CT cycle, 34: 2 cycles, and 15: 3 cycles. The most frequent and severe acute toxicities were mucositis with grade 3-4 occurring in 28% at cycle 1 and 86% at cycle 2, as well as neutropenia (43% at cycle 2). Locoregional control at 6 months was observed in 66.7% of patients. No late toxicity above grade 2 RTOG was noticed. CP dose and 5-FU AUC(0-105h) were significantly linked to grade 3-4 neutropenia (cycle 2). Cumulative total platinum (Pt) concentration and Karnofsky index were the only independent predictors of locoregional control at 6 months. Finally, total RT dose and total Pt concentration were the only independent predictors of specific survival. CONCLUSION: This protocol showed good locoregional response with an acceptable toxicity profile. Pharmacokinetic survey is probably an effective approach to further reduce toxicity and improve efficacy. A multicentric randomized phase III study, now underway, should confirm these encouraging results.

[Combination treatment for pilocytic astrocytoma: stereotaxic radiosurgery and endocavitary radiotherapy]. / Traitement combiné d'un astrocytome pilocytique: radiochirurgie stéréotaxique et radiothérapie endocavitaire.

The treatment of a pilocytic astrocytoma located in a functional area can be performed using radiosurgery. We report a 7 year old male, right-handed, who presented with a pilocytic astrocytoma in the left parieto-occipital lobe. After a 7 year follow-up, the tumor became symptomatic (partial and generalized seizures). The CT scan and nuclear magnetic resonance imaging revealed an increased size of the mural tumor and the development of a cystic component. Multi-beam irradiation of the tumor (dose of 30 Gy at the center with 21 Gy on the isodose 70%) was performed with a LINAC for radiosurgery coupling a modified Saturne 18 MeV linear accelerator and a Talairach stereotactic frame. Following multi-beam irradiation, the increase in size of the cyst imposed further intracavitary radiation using Rhenium 186 (186Re) to deliver 400 Gy to the cyst wall. After a period of intense cerebral edema, resolutive with steroid treatment, we obtained progressive cyst disappearance and mural nodule retraction. A PET scan, performed 3 years after this treatment, revealed no metabolic activity in the persistent mural nodule. The patient remains totally asymptomatic.

[Dosimetric quality control in stereotactic radiotherapy with the aid of radiosensitivity]. / Contrôle de qualité dosimétrique en radiothérapie stéréotaxique à l'aide de gels radiosensibles.

Typical dosimeters used in stereotactic radiation therapy, such as ionization chambers, films, and thermoluminescent diodes, allow basic physical measurements. They are, however, neither well suited to discern small target volumes with high dose gradient, nor suitable for three-dimensional (3D) dose measurements. Gel dosimetry is becoming more and more interesting, owing to magnetic resonance imaging (MRI). It permits isocenter position planning verification of accuracy and the precision of the 3D dose mapping in the brain (when irradiated in realistic conditions), especially when several different targets are concerned. Many authors have assessed stereotactic radiation therapy quality control using different gels, and different irradiation procedures. This paper consists of the review of these different methods to assess quality control. Gel dosimetry cannot provide absolute dose measurements. However, gels can be used to check the 3D dose mapping with a high degree of detail. In our experiment, the difference between the stereotactic frame center and the isocenter is about 1 mm. The difference between the theoretical isodoses obtained by the treatment planning system and the experimental isodoses obtained by the MRI gray level calibration is also about 1 mm, the order of magnitude of the MRI pixel size.

[Pituitary radiotherapy. Current data and future prospects]. / Radiothérapie hypophysaire. Données actuelles et perspectives d'avenir.

Some technical improvements have allowed to minimize the frequency of severe complications following fractionated pituitary conventional radiotherapy, without altering its efficiency. "Conformational" radiotherapy is currently under development, aiming at the best fitting of the tumor borders to the irradiation zone, by the means of stereotactic imaging. More recently, radiosurgery has been proposed for pituitary adenomas. It consists in a single high radiation dose to the tumor, by the means of either cobalt minibeams (Gamma Unit) or photon beams from a linear particle accelerator. These techniques require the use of a stereotactic frame and precise 3D imaging in order to tightly superimpose the target volume to the reference isodose. They must not be viewed as an alternative to conventional radiotherapy. They can be applied only to small lesions (less than 20 mm in their maximal axis) which are distant (> 5 mm) from the optic chiasma and nerves. Their efficiency is similar to the one of fractionated conventional radiotherapy, with a shorter response time. In conclusion, radiotherapy can be used safely for pituitary adenomas. It remains however a second line treatment, when surgery has been incomplete and when a simple, effective and inexpensive medical treatment is not possible.

Epilarynx: pharynx or larynx?

BACKGROUND: As a general rule, epilarynx is studied as a part of supraglottis. On the contrary, in France, due to its particular natural history, it is often studied separately. METHODS: To assess the value of this French classification, we compared from an epidemiologic point of view, in one study, 86 cases of epilarynx squamous cell carcinoma (SCC) with 431 oropharynx, 339 hypopharynx, and 89 vestibule SCC. In another study, we compared, from a clinical point of view, 232 epilarynx SCC with 1351 oropharynx, 652 hypopharynx, and 372 vestibule SCC. RESULTS: Epilarynx patients appeared to be much heavier drinkers than larynx patients and similar to pharynx patients but tobacco consumption did not differ. The patterns of nodal involvement were similar for pharynx and epilarynx SCC. For stages I and II, patterns of failures were similar, but for stages III and IV, there were fewer locoregional failures in vestibule patients; distant metastases were equally frequent for these tumors. From the standpoint of multiple primaries, epilarynx SCC appeared to be more akin to pharynx than to larynx SCC with a much lower incidence of lung cancers. Finally, the outcome after treatment was different for vestibule, epilarynx, and pharynx SCC, with a 5-year survival of 43%, 27%, and 13%, respectively. CONCLUSIONS: These data support the identification of epilarynx as a real entity that should be taken into account for stratification in clinical trials.

Management of early oral cavity cancer. Experience of Centre Oscar Lambret.

From 1974 to 1983, 579 patients presenting with early oral cancer (excluding lip tumours) were treated at Centre Oscar Lambret. Of these, 429 were treated locally by brachytherapy with local control achieved in 82% of the cases (90% after salvage surgery). Treatment-related complications occurred in 19% of the cases, requiring surgical management in 13 patients. In contrast, only 51% of the 35 patients treated by external radiotherapy and brachytherapy were controlled, resulting in a poor 5-year survival (14%). Results for the 24 patients treated surgically were similar to those of brachytherapy alone. Finally, for T1 T2 N0 patients, the advantages of an elective neck dissection are not clear and could be clarified by a randomised trial. Indeed, this retrospective study failed to find a significant difference in the incidence of death due to an uncontrolled neck evolution whatever the neck management.

Composite resection with mandibulectomy in the treatment of posterolateral oral cavity and lateral oropharynx squamous cell carcinoma.

From 1972 to 1987, 403 patients underwent a composite resection consisting of segmental mandibulectomy and neck dissection for the treatment of bucco-pharynx squamous cell carcinoma (303 patients had postoperative radiotherapy [XRT], 29 patients had preoperative XRT, and 100 patients had tissue salvage performed after XRT). Of the 303 patients who received preoperative XRT, 32 were clinically staged T2, 149 were staged T3, and 122 were staged T4; 194 of the 303 patients were staged N0. In the 100 patients who experienced relapse and who required "salvage surgery," the restaging found 20 patients staged T2, 39 staged T3, and 41 staged T4; 73 of the 100 patients were staged N0. The patients' mean postoperative stay was 15 days for those who had prior surgery and 21 days for those who had salvage surgery. With a minimum follow-up of 5 years, locoregional recurrences and postoperative death occurred in 86 of 274 patients (31%) in whom surgery and postoperative XRT were performed; in 17 of 29 patients (59%) who had preoperative XRT performed; and in 61 of 100 patients (61%) who had salvage surgery performed. In addition, in terms of functional results, only 61% of patients (206) were able to maintain normal speech function, and only 23% (91) were able to maintain normal oral feeding. Of the 403 patients, the 5-year survival rates were 33% for the overall population, 42% for patients with postoperative XRT, 16% for patients in whom operation was performed after preoperative XRT, and 17% for patients who underwent salvage surgery.

Stereotactically guided radiosurgery using the linear accelerator.

Leksell initiated the concept of stereotactic radiosurgery in 1951. This last decade has seen a rapid proliferation in the development of the methodology which is certainly related in part to the simultaneous growth of high-resolution neuro-imaging techniques. By focusing the beams of 201 hemispherically arrayed cobalt 60 sources, the gamma-knife delivers a high dose of radiation to a small target. Another possibility proposed by several authors is the bragg peak cyclotron-generated irradiation with accelerated protons or helium ions. In Lille, since 1988, we have chosen to develop stereotactic radiosurgery, according to the system of Betti, by the association of Talairach's stereotactic methodology and external single-dose encephalic irradiation with high energy X-rays, delivered by means of a linear accelerator. The major indication for the use of this method is an arteriovenous malformation. Stereotactic radiosurgery may be proposed alone or in combination with surgery and embolisation. It has been shown to be a potentially effective treatment and an attractive alternative in carefully selected patients with intracranial tumours: slow-growing, well limited, deep-seated tumours, such as some gliomas, acoustic neurinomas, skull base meningiomas, pituitary adenomas. This treatment is also used to deliver a focal boost of radiation to previously administered fractionated radiotherapy in patients with small gliomas and solitary brain metastases.

Comparison of surgery and radiotherapy in T1 and T2 glottic carcinomas.

We retrospectively studied 356 patients who received treatment for T1 and T2 glottic carcinomas. Two hundred and thirty patients were treated with surgery (200 by cordectomy, 15 by vertical partial laryngectomy, and 15 by subtotal laryngectomy). Radiotherapy was used to treat 126 patients. There were 206 T1 and 24 T2 lesions in the surgically treated group and 107 T1 and 19 T2 lesions in the radiotherapy group. Sixty-four patients received radiotherapy because it was the treatment of choice (scheduled radiotherapy) and 62 patients received radiotherapy because they had medical contraindications for surgery (default radiotherapy). Actuarial survival rates at 5 years were 84% for patients who underwent surgery and 78% for patients who underwent scheduled radiotherapy. In the surgically treated group, there were 10 local recurrences in 170 patients with tumors of the true vocal cord, eight recurrences in 36 patients with anterior commissure lesions, and 6 recurrences in 24 patients with tumors extending to the arytenoid. In the scheduled radiotherapy group, there were 7 local recurrences in 38 patients with true vocal cord tumors, 6 recurrences in 20 patients with anterior commissure tumors, and 5 recurrences in 6 patients with tumors extending to the arytenoid. We conclude that survival is similar in these patients whether they receive operative treatment or scheduled radiotherapy. However, in the radiotherapy group, local recurrences were more frequent in patients with tumors extending to the arytenoid. We advocate extended functional surgery for patients with T1 and T2 glottic lesions except for those with small tumors arising from the middle third of the vocal cord.