Early and long-term results of an original accelerated radiation therapy schedule in head and neck carcinoma.

From November 1985 until October 1988, 39 patients with head and neck carcinoma (6 patients stage I-II and 33 stage III-IV) were treated with an accelerated radiotherapy schedule designed to deliver 69.6 Gy over a period of 5 weeks. Treatment was started with 20 Gy in 10 daily fractions to sites of initial macroscopic involvement, followed by bi-fractionated radiotherapy (2 x 1.6 Gy/day) to a larger head and neck volume. Twenty patients received neo-adjuvant chemotherapy. A homolateral radical neck dissection was performed in 2 patients. Twenty-six patients (66.6%) presented with acute grade 3 complications and 5 patients (13%) with grade 4 complications. Thirteen patients (33.3%) were hospitalized for supportive care. None of the patients who were evaluated on a long-term basis developed grade 3 or 4 late complications. The 5-year loco-regional control and overall survival rates were 62.4% and 33.6% respectively. Although acute toxicity is higher than in monofractionated schedules, it is manageable, and can be considered acceptable in the light of the apparently good loco-regional control thus obtained. This schedule is one of several accelerated radiotherapy programs which might merit study in prospective trials.

Chemoradiotherapy versus radiotherapy alone for anal cancer: a retrospective comparison.

PURPOSE: To evaluate the effect of adding one cycle of concomitant chemotherapy to curative radiotherapy on tumor control and toxicity in the treatment of anal cancer. METHODS AND MATERIALS: One hundred twenty-five patients completed curative sphincter-conserving treatment, 57 with radiotherapy alone and 68 with concomitant chemo-radiotherapy. Compared with chemoradiotherapy patients, radiotherapy patients were older (median age 71 vs 63) and had less advanced tumors (T3-4 26% vs 51%). Radiotherapy patients were usually treated with a direct perineal cobalt field (mean dose 31 Gy at 5 cm/10 fractions/3 weeks), complemented in most cases by a sacral are field, followed (mean split 54 days) by Iridium-192 implantation (mean dose 23 Gy, Paris system). The large majority of chemoradiotherapy patients received antero-posterior opposed 10 MV photon fields, including pelvic and inguinal nodes (mean dose 38 Gy/19 fractions/4 weeks), followed (mean split 42 days) by implant boost (mean dose 18 Gy). In addition, chemo-radiotherapy patients received starting on day 1 an IV bolus of Mitomycin-C, 0.4 mg/kg (maximum 20 mg) and a 5-day continuous infusion of 5-fluorouracil 600-800 mg/m2/day. Median follow-up was 65 months for radiotherapy and 48 months for chemo-radiotherapy patients. RESULTS: For all 125 patients at 5 years, overall survival was 65.5%, definitive local control 83% and local control with sphincter preservation 68%. Overall and stage for stage, there was no difference in overall, progression-free or cancer-specific survival, nor in local control, local-regional control, or sphincter preservation rates between patients treated with chemoradiotherapy vs. radiotherapy alone. There was no significant difference between the two groups regarding acute or late toxicity. CONCLUSION: This retrospective analysis does not confirm the efficacy of one course of simultaneous Mitomycin-C and 5-fluorouracil, at least in association with full-dose radiotherapy incorporating Iridium-192 boost.

[Epidermoid carcinoma of the anal canal. Value of a multidisciplinary approach]. / Les carcinomes épidermoïdes du canal anal. Intérêt d'une approche multidisciplinaire.

Great progress has been achieved in the clinical diagnosis, the pathologic patterns study and the treatment of anal epidermoid carcinomas. External and interstitial radiotherapy in association with chemotherapy offers today a real chance to cure these lesions and to save sphincter function. Incidence in actinic lesions is reduced. Salvage abdominoperineal excision is still possible in case of local recurrence without delay in wound healing. 95 cases of anal epidermoid carcinoma were treated in the University cantonal Hospital of Geneva by a combined radio-chemotherapy approach. Local control has been achieved in 86% of tumors less than 4 cm in diameter and 73% of tumors more than 4 cm in diameter. Salvage abdomino-perineal excision has been required in 10% of cases. Abdomino-perineal excision is no more the first treatment of choice of anal epidermoid carcinoma.

Surgery as part of a combined modality approach for inflammatory breast carcinoma.

From November 1977 to February 1984 21 patients with inflammatory breast carcinoma (IBC) were treated in a prospective, nonrandomized study with initial chemotherapy, consisting of a combination of chlorambucil, methotrexate, 5-fluorouracil, and doxorubicin. Modified radical mastectomy was performed after three courses of chemotherapy followed by another six courses of the same chemotherapy. Locoregional radiotherapy concluded the treatment program. All patients responded clinically to the initial chemotherapy. Modified radical mastectomy provided a direct histologic control of the effectiveness of the treatment and, in case of tumor persistence, allowed cytoreduction. No scarring problems were observed and postoperative chemotherapy could be administered without any delay. Radiotherapy was decisive for locoregional tumor control which was obtained in all patients who were treated strictly according to the protocol. Dermal lymphatic involvement represented in this series of clinical inflammatory breast carcinoma no pejorative feature and positive hormone receptors failed to be of predictive value for response to treatment. Considerably variable tumor persistence after initial chemotherapy and the results relative to local tumor control advocate surgery as part of a combined modality approach for inflammatory breast carcinoma.

[Transplantation of allogeneic bone marrow treated in vitro with Campath-1 monoclonal antibody]. / Transplantation de moelle osseuse allogénique traitée in vitro par l'anticorps monoclonal Campath-1.

Out of 14 bone marrow transplants, 12 patients received transplantations with allogeneic bone marrow after in vitro T-cell depletion with monoclonal Campath 1. The patients also received short term cyclosporin. This small series is in agreement with the results of larger series using T-depleted marrow as far as the prevention of graft versus host disease is concerned, and with respect to mixed chimerism, slow take, late rejection and, possibly, increased risk of recurrence.

[Intensive treatment and autologous bone marrow transplantation in cases of acute leukemia and lymphoma]. / Traitements intensifs et transplantation de moelle osseuse autologue en cas de leucémies aiguës et de lymphomes.

Experience with 19 autologous bone marrow transplantations shows that this approach may produce a high proportion of complete remissions in otherwise resistant tumours. Although most responses are of short duration, they suggest that longterm disease-free survival may be achieved in patients with poor prognosis if treated earlier in the course of disease.

[Transplantation of allogeneic bone marrow treated in vitro with Campath-1 monoclonal antibody]. / Transplantation de moelle osseuse allogénique traitée in vitro par l'anticorps monoclonal Campath-1.

5 patients underwent bone marrow transplantation for severe aplastic anemia (2) and acute leukemia (ALL) in first remission (3). Graft versus host disease prophylaxis was performed by depleting T lymphocytes in the donor bone marrow with the rat monoclonal Campath-1 and autologous complement. In addition, patients received cyclosporin A. Engraftment occurred normally in all 5 patients but 1 patient (SAA) had a late graft failure. Two patients suffered mild degrees of GvHD. All patients are currently in complete remission, one having undergone a second transplantation.

[Intensive treatment and autologous bone marrow transplantation in cases of leukemias and lymphomas in relapse]. / Traitements intensifs et transplantation de moelle osseuse autologue en cas de leucémies et de lymphomes en rechute.

This study shows that autologous bone marrow transplantation is feasible and can produce a high proportion of complete remission in otherwise resistant tumors. Although most responses are of short duration, they suggest that long-term disease free survival could be achieved in patients treated earlier in the disease course.

[The place of radiotherapy in the treatment of lymph node metastases in the neck from upper respiratory and digestive tract neoplasms]. / Place de la radiothérapie dans le traitement des adénopathies métastatiques cervicales des carcinomes des voies aéro-digestives supérieures.

The management of lymphnode disease is a common denominator in the treatment of all head and neck cancers. Only in a few clinical situations does irradiation or surgery alone yield a satisfactory control rate. The rationale for combination of both disciplines is based on two facts: a) Irradiations (5000 rads in 5 weeks) can eradicate the microscopic disease that a radical surgical procedure cannot remove; b) high doses of irradiation fail to control large cancer volumes (6500 rads in 6-7 weeks to a lymphnode greater than or equal to 3 cm: about 20% recurrence rate). The therapy sequence must be flexible and depend on clinical factors. The radicalism of both disciplines should be reduced in order to diminish the complication rate.

Preliminary results using twice-a-day fractionation in the radiotherapeutic management of advanced cancers of the head and neck.

Twenty-four cases of advanced T4 cancers of the head and neck were treated using a twice-a-day treatment fractionation delivering a 1,200 rad weekly tumor dose and 7,000 rad total tumor dose in 5 1/2-6 weeks. Acute normal mucosal reactions and skin reactions were plotted weekly and corresponded to reactions observed when delivering 1,000 rad per week in five treatment sessions. Chronic problems have been limited to severe neck fibrosis appearing in three of five patients who underwent a planned neck dissection 6 weeks after the completion of radiotherapy. Local control was observed in 14 of 23 patients (61%) and regional control in 22 of 23 patinets (96%).

[Evolution of the dosimetric criteria of the curietherapy in carcinoma of uterine cervix (author's transl)]. / Evolution des critères dosimétriques de la curiethérapie des cancers du col utérin.

The difficulties which arise when comparing the different therapeutic attitudes concerning the treatment in the curable stages of cancer of the uterine cervix have led us to the formation of dosimetric criteria to be employed in the analysis of the intracavity therapy. We have established points of reference which can be utilized irregardless of the intracavitary technique therapy. We have established points of reference which can be utilized irregardless of the intracavitary technique employed. Furthermore, we have analysed those patients who have received the same dose of external irradiation in an effort to establish as the only variable the intracavitary treatment. Forty patients, receiving 4,000 rads tumor dose in 4 weeks, were reviewed and demonstrated a correlation between the reference volume of the intracavitary treatment (as defined by the three dimensions W, H, T) and eventual complications (4 cases of Rectitis 1). We now feel that with the utilisation of these dosimetric criteria we will be able to: minimize the risk of complication without augmenting the indicence of local-regional failures; facilitate the objective comparison of the efficacity of the different intracavitary techniques presently employed at the major treatment centers.

[A universal remote afterloading projector for gynecological curietherapy (author's transl)]. / Un projecteur universel pour la curiethérapie gynécologique: le Gynatron

The Gynatron is a remote after loading system for gynecological radioactive applications. It allows the responsible personal to manually load the sources from outside of the patient's room. It's main advantages are: 1 degree A mechanical breakdown is virtually impossible because of the absence of a motorized system. 2 degrees It can be used with all types of applicators and all types of radium substitutes. The system described was used with cesium sources and Fletcher applicators. The radiation protection remains optimal during the treatment of the patient as well during the manipulation of the sources from the fixed to the mobile safe (Gynastock) as when there is a need to change the loading.