Intraoperative radiation therapy in recurrent carcinoma of the uterine cervix: report of the French intraoperative group on 70 patients.

PURPOSE: To evaluate the feasibility and oncologic results of intraoperative radiation therapy (IORT) for recurrent uterine cervical carcinoma in a cohort of patients treated in seven French institutions. METHODS AND MATERIALS: From 1985 to 1993, 70 patients with pelvic recurrences underwent IORT with/ without external radiation therapy (ERT) and chemotherapy (CT). Treatment modalities for recurrence were IORT alone (40 out of 70), IORT + ERT (30 out of 70), additional chemotherapy (20 out of 70). Gross complete resection (CR) was performed in 30 out of 70 cases, partial resection (PR) in 37 out of 70, and unspecified surgery in 3 out of 70. Sixty-five patients had electron beam IORT and 5, 100 KV photon IORT. Mean IORT cone size, electron beam energy, and dose (calculated at the 90% isodose line) were, respectively, 75 mm (40 to 90), 12 MeV (6 to 20), and 18 Gy (10 to 25) after CR and 80 mm (45 to 100), 15 MeV (7 to 24), and 19 Gy (10 to 30) after PR. RESULTS: Mean follow-up after IORT was 15 months (2 to 69). One, 2- and 3-year overall survival rates were 47, 17, and 8%, respectively; median survival was 11 months and local control, 21%. Median survival and local control rates increased after CR (13 months, 27%) vs. PR (10 months, 17%) and when initial treatment consisted of surgery (S) alone (15 months, 25%) vs. radiation therapy (RT +/- S) (10 months, 16%). However, these differences were not statistically significant. No death-related toxicity was observed. Grade 2 or 3 toxicity was observed in 19 out of 70 patients (27%), including 9 not directly IORT-related complications (13%) (three digestive tract fistulas, one rectal stricture, three urinary fistulas, two infections) and 10 directly IORT-related complications (14%) (five neuropathies, four ureteral obstructions, and one rectal stricture). CONCLUSION: This retrospective study demonstrates the feasibility of IORT. The usefulness of IORT still needs to be evaluated in primary treatment of advanced stages of cervical carcinoma.

[Well-differentiated papillary mesothelioma of the peritoneum: an attenuated malignant tumor. Review of the literature apropos of a case]. / Le mésothéliome péritonéal papillaire bien différencié: une tumeur à malignité atténuée. Revue de la littérature à propos d'un cas.

The authors present a new case of a well-differentiated papillary mesothelioma of the peritoneum. This is an uncommon tumor which have a slow evolution like a low malignant potential tumor. But, because of its tendency to recurrence, the designation of Well-Differentiated Tumor is better. The diagnosis with others peritoneal tumors is sometimes difficult, especially with the Peritoneal Serous Tumors. Tumor recurrence must be treated by curative surgery. Adjuvant therapy is discussed for the diffuse form.

[Splenic metastases. Apropos of 4 cases]. / Les métastases spléniques. A propos de 4 observations.

The authors report about 4 cases of splenic metastases in patients with the following neoplasms: urothelial carcinoma of the left kidney, adenocarcinoma of the uterine body, adenocarcinoma of the left flexure of the colon, adenocarcinoma of the sigmoid loop. On large autopsy series, metastases to the spleen are not rare (7% in average), and rank 10th among the 44 metastatic sites described in the literature. Cancers of the breast, lung, skin (melanoma), ovaries and stomach (cardia) make up more than 60% of the primary tumors. The diagnosis is most often accidental (surveillance of operated patients), rarely clinical (pain, splenomegaly), and it is based on medical imaging (ultrasound, CT). In the absence of hemostatic disorders, percutaneous needle biopsies are possible. Treatment, when at all possible, is surgical (splenectomy) and must comply with carcinological rules.

[Breast reconstruction with inferior transverse abdominal flap after mastectomy for cancer]. / La reconstruction mammaire par lambeau abdominal transverse inférieur après mastectomie pour cancer.

Breast reconstruction with an inferior transversal abdominal flap provides good quality cosmetic results. Indications for this flap technique are presently limited because of the frequency of complications in early series. The aim of this study was to evaluate the different parameters which could reduce the number of complications. From January 1989 to July 1991, 25 patients were treated with this method at the René-Gauducheau Centre. All patients were treated with the same surgical technique. Based on the complications observed in this series and a review of the literature, we were able to determine those factors which could limit the number of complications. Preoperative patient selection defined a population at risk of vascular complications. This population corresponded to a good indication for double pediculated flaps. Global flap removal, the muscle and the anterior sheath of the aponevrose together, and maintaining the patient in a sitting position for five days after the operation helped reduce the frequency of complications. Folding the abdominal wall with a nonabsorbable sheath appeared to be a simple and reliable method of reducing the number of abdominal complications. The double pediculated flap was indicated in all cases at risk of partial necrosis or when a large volume was necessary to avoid asymmetry. Using this type of management, breast reconstruction with inferior transversal abdominal flap is the first intention technique used at the René-Gauducheau Centre in Nantes.

[A new approach to the axilla: functional axillary lymphadenectomy and padding]. / Une nouvelle approche du creux axillaire: lymphadénectomie axillaire fonctionnelle et capitonnage.

Axillary lymph node dissection, which is now mandatory in the conservative breast cancer surgery and classically involves Berg's two lower levels, is burdened with numerous complications. In 1988 and 1989, two technical modifications were introduced and are described here: padding of the axilla as preventive treatment of postoperative lymphocele and, more recently, functional axillary lymphadenectomy (FAL) in which the medial cutaneous nerve of the arm, the two perforating intercostal nerves and above all the lateral thoracic pedicle (external mammary artery and vein) are spared. These two technical innovations, more respectful of anatomy, are aimed at reducing the morbidity of conservative breast cancer at a time when detection enables breast cancers to be treated at an increasingly early stage, which results in a increase of negative axillary dissections. The postoperative period is simplified (no drainage, immediate mobilization), and the hospital stay is reduced to 2 days. Complementary treatments can thus be started early on, without any functional or cosmetic damage while the number of lymph nodes removes remains the same as in the conventional axillary dissection technique. The authors describe the operative procedures and analyse the 100 cases of conservative breast cancer they have treated with padding and FAL. These two technical modifications are now systematically used by them in the management of breast cancers.

[Fibroma of the breast. A clinicopathologic study of a case]. / Fibromatose mammaire. Etude anatomo-clinique d'un cas.

Fibromatosis is a fibroblastic proliferation which has infiltrative properties and which is not expected to metastasize. Mammary fibromatosis is infrequent. Clinically, it may mimic breast carcinoma. So, the diagnosis is made from the microscopic examination. Wide local excision is the treatment of choice. But, local recurrence are frequent.

[Wadding of the axilla in the conservative treatment of cancer of the breast. Prevention of lymphocele]. / Le capitonnage du creux axillaire dans le traitement conservateur du cancer du sein.

A randomized prospective study was carried out on 53 consecutive female breast cancer cases hospitalized at the Centre René Gauducheau, In Nantes (France), with the intent of investigating whether surgical wadding of the axillary fossa with the use of proximate muscular tissue can prevent lymphocele from occurring, and avoid placement of suction drains usually required in conservative management of breast cancer. Results have been significant regarding the incidence of lymphocele (p less than 0.001), as well as the mean puncture volume and the total number of punctures needed (p less than 0.001), thus reflecting the efficacy of a simple method, which yields satisfactory cosmetic results. Failures with this method were related to the technical procedure per se, and not to its principle. The lapse of time required before additional treatment was initiated as subject to a factor not related to the method, but depended upon the recovery of normal shoulder mobilization.

Biodistribution of indium-111-labeled OC 125 monoclonal antibody intraperitoneally injected into patients operated on for ovarian carcinomas.

The biodistribution of 111In-labeled monoclonal antibody (MAb) OC 125 was studied after i.p. injection in 28 patients who underwent surgery for ovarian carcinoma. Group I (eight patients) received intact 111In-labeled OC 125 MAb, Group II (three patients) intact 111In-labeled irrelevant NS, Group III (five patients) intact 111In-labeled OC 125 MAb associated with 20 mg of the same unlabeled MAb and Group IV (12 patients) F(ab')2 fragments of 111In-labeled OC 125 MAb. The patients were operated on 1 to 3 days after i.p. injection, and the surgeon removed large tumor fragments and/or small tumor nodules and, in some patients, collected the residual perfusion fluid from which malignant cell clusters were isolated. Uptake by large tumor fragments at 24 h was low: 0.0031 +/- 0.0032% injected dose per gram (%ID/g) for Group I and 0.0024 +/- 0.0022%ID/g for Group IV. It was moderately higher than that of Group II (0.0014 +/- 0.0006%ID/g) and Group III (0.0015 +/- 0.0007%ID/g). Uptake by small tumor nodules (0.1302 +/- 0.0802%ID/g at 72 h for Group I) and malignant cell clusters (median: 0.3322, with a maximum value of 4.1614%ID/g at 24 h for Group IV) was markedly higher. Tumor-to-normal tissue ratios with OC 125 MAb [intact or F(ab')2 fragments] ranged between 0.1 and 8.5 for large tumor fragments and 2 and 8,700 for small tumor nodules and malignant cell clusters. It would thus appear that RIT is feasible if an appropriate radionuclide can be selected for antibody labeling.

Immunoscintigraphy of recurrences of gynecologic carcinomas.

In a first, retrospective study, 15 patients with known ovarian carcinoma were injected with 131I-OC 125 F(ab')2 monoclonal antibody (MAb). The sensitivity of immunoscintigraphy based on the number of the tumor sites was 67% (12/18). In a second, prospective study, 29 patients with gynecologic carcinoma were injected with 131I-OC 125 F(ab')2 (24) or 131I-19-9 F(ab')2 (5) MAbs according to the histologic type. Based on the number of tested anatomic sites, sensitivity was 72% and specificity 86%. In two patients injected with both 131I-OC-125 F(ab')2 and 125I-NS F(ab')2 (nonspecific immunoglobulin) 1 and 4 days before tumor resection, tumor uptake of the specific antibody was 2.2 and 4.5 times greater than that of NS. Immunoscintigraphic results were complementary with those of ultrasonography and computed tomography. Finally, in one patient injected successively with 131I-OC 125 F(ab')2 and 111In-DTPA-OC 125 F(ab')2, the recurrent tumor was visualized with both radionuclides, with 111In providing better abdominal tumor contrast but causing much greater liver radioactivity than 131I.

[Immunohistochemical study of 4 cases of mucoid and argyrophilic carcinoma of the breast]. / Etude immunohistochimique de 4 cas de carcinomes mucoïdes et argyrophiles du sein.

Three to 5% of breast carcinomas are argyrophilic, including some which are mucinous and thus "composite", whereas there are no argyrophilic cells in normal breast nor in benign breast pathology. This raises the problem of the origin and type of these argyrophilic cells. We carried out a histologic and immunohistochemical study in 4 such cases of mucoid tumors containing at least 50% argyrophilic cells. Two of these tumors presenting node involvement were also studied immunohistochemically. The histologic study showed colloid and intragalactophoric proliferation areas in cell cases and some endocrine areas in 2 out of 4 cases. Argyrophilic cells were present in all of these areas. True mucoargyrophilic amphicrine cells were found primarily in colloid areas. None of these tumors were argentaffin. Immunohistochemical study was performed by the PAP method using antibody directed against VIP, ACTH, PP, somatostatin, bombesin, calcitonin, gastrin, prolactin and GH. Three out of four tumors were positive with VIP. Moreover one of them contained ACTH cells and a metastasis of this tumor contained bombesin cells. No tumor was positive with the other anti-sera tested. This study is related to the rare series in the literature which report secretion of ACTH, catecholamins, bombesin, gastrin, VIP, PP, somatostatin, prolactin, etc. The number of cases reported to date remains too low to show a significant prognostic difference between amphicrine tumors and other mammary carcinomas.

[Cancer of the vulva. Diagnostic and therapeutic aspects apropos of a series of 90 cases]. / Cancer de la vulve. Aspects diagnostiques et thérapeutiques à propos d'une série de 90 cas.

The authors present a series of 90 cases of cancer of the vulva of which 10 were intra-epithelial and 80 were invasive. These were studied from the 1st January 1962 through to the 31st December 1980. The mean age was 70.04 years, the range being from 31 to 92 years of age. Most cases however were between the ages of 70 and 80. 37.7% of the patients were debilitated. The condition was brought to notice by the discovery of a tumour in 48.8% of the cases, the onset of pruritus in 20% of cases and pain in 14.4%. Most of the tumours were found on the labia majora and minora (in 52.2%). FIGO classification was of stage I in 12% of cases, stage II in 26.6%, stage III in 33.3% and stage IV in 28%. The methods for treating these conditions have been shown according to whether the tumour was intra-epithelial or invasive. Analysing the results confirms that this kind of cancer has a poor prognosis: 57.6% of survivors after 2 years but only 37.3% after 5 years (an actuariel calculation). 30 cases of relapses were analysed and also the complications that occurred. Among these were most frequently (25%) lymphocoeles, sutures falling out because of necrosis and infection (34.2%), urinary incontinence (35.2%). The circumstances in which the patients died were determined above all by the way the disease evolved locally, but in 13.3% of the cases there was metastatic disease. Finally, the difficulties of the diagnosis and of the definition of micro-invasive cancer of the vulva are commented on. The authors point out that the prognosis depends as much as anything on the amount the lymphatics are involved, the frequency and the problems of therapy that are posed by urinary incontinence which occurs after operation. They then give their ideas for treating the patients.