[Conservative treatment of breast cancer (the Lyon experience during 1963-1983)]. / Traitement conservateur du cancer du sein (expérience lyonnaise 1963-1983).

Over a 20-year period (1969-1983), 570 infiltrating primary breast carcinomas were conservatively treated in Lyons. Two different protocols were used: a first group of 162 patients with T1 T2 less than 3 cm NO lesions was treated, between 1963 and 1973, by lumpectomy and external beam irradiation with 60cobalt. The 5 and 10 year overall survival rates are 86% and 66% respectively. Local and regional failure rates are 10% and 2.5%. Cosmetic result was good or excellent in 70% of patients with only 5% poor results; a second group of 408 patients with T1 T2 less than 3 cm lesions was treated between 1973 and 1983 by tumorectomy and axillary dissection, followed by cobalt irradiation and 192iridium boost. The 5-year overall survival rate was 90% and, at 5 years, the probability of failure is 5% in the breast and 2% in the axilla. Cosmetic results are comparable in the 2 groups. Comparison of these 2 groups indicates an improvement in local control with Iridium boost. No obvious change in axillary recurrence rate and overall survival rate was observed. Boost modalities are discussed, with regard to cosmetic results. A prospective randomized study was initiated in 1986, in order to assess the value of the boost in the conservative treatment of breast cancer.

Initial chemotherapy and low-dose radiation in limited fields in childhood Hodgkin's disease: results of a joint cooperative study by the French Society of Pediatric Oncology (SFOP) and Hôpital Saint-Louis, Paris.

To minimize the drawbacks of treatment we had shown in a previous study that it was possible after chemotherapy to limit the radiation fields to the involved areas only. Pursuing our policy of deescalation, we started in January 1982 a study in 29 French pediatric and hematologic centers, with two aims: (1) To compare the efficacy of 4 cycles of two different chemotherapeutic regimens (4 ABVD vs 2 MOPP + ABVD) in early stages (CSIA and II A) while other stages would receive 6 cycles of the same regimen (3 MOPP + 3 ABVD); (2) To evaluate the efficacy of irradiation given at a low dose (20 Gy) in the patients who had a minimum 70% reduction of the size of their nodes (good responders). From January 1982 to March 1987, 174 patients were entered in this study, of whom 157 completed their treatment program at the time of analysis. On completion of chemotherapy, 94% were considered as good responders and were irradiated to 20 Gy. Only 6 patients received a mediastinal boost (up to 40 Gy). Of the 6% (10/157) poor responders a complete remission was obtained in 6 after 40 Gy. Among the good responders, 5 patients relapsed, with only 3 within an area irradiated to 20 Gy. So that 4 nodal relapses occurred among 364 involved lymph areas. The actuarial survival at 42 months (median 30 months) is 95% (IA + IIA = 100%, IB + IIB + III = 94% and IV = 80%) and the disease-free survival 88% (respectively 94, 93 and 54). Until now there is no statistically significant difference between the 2 randomized arms. This study shows that it is possible to achieve a durable remission in most children treated with a less toxic protocol eliminating or reducing Nitrogen Mustard and reducing the dose of irradiation. Less late complications and sequelae are expected with a longer follow-up.

[Radiotherapy of cerebral metastases. 196 cases treated from 1973 to 1981]. / La radiothérapie des métastases cérébrales. 196 cas traités de 1973 à 1981.

One hundred and ninety six patients underwent brain irradiation for metastases between 1973 and 1981. Complete follow-up was possible in 180 cases. CT appeared to be the best diagnostic tool. Whatever the type of the tumor, irradiation improved symptoms and signs in 65.3 p. 100 of cases and neurological status in 37 p. 100 of cases. The median survival was 4.2 months, the mean survival 6.6 months, the percent survival at 1 year 11 p. 100. It is necessary to irradiate the whole brain with doses of 40-45 Gy in 4.5 weeks. Shorter periods of irradiation allows a short inhospital stay but implies anti-oedematous treatment. Chemotherapy did not improve the results. Excision surgery had limited indications: isolated metastases, accessible site in zones with no functional importance, good performance status, local control obtained for primary tumor, no extra-cerebral metastases. Surgery must be followed by whole brain irradiation. Derivation is necessary when increased intracranial pressure and treatment resistance are present. Irradiation indications are large. The results were palliative but valuable: irradiation was always indicated except when disorders of consciousness were present. Tolerance was usually good.

[Major beta-thalassemia and bone marrow allograft. Two cases and a study of the literature]. / Bêta-thalassémie majeure et allogreffe médullaire. Deux observations et une étude de la littérature.

A 5 year 9 month-old boy has received a bone marrow allograft for beta-thalassaemia major. Conditioning included busulfan: 16 mg/kg, cyclophosphamide 200 mg/kg and a (6 Gy) thoracoabdominal irradiation. After a 16 months follow-up, the child is currently in complete remission without treatment with all the markers of his donor. His 9 year-old sister has been allografted for beta-thalassaemia major, with the same conditioning regimen. After engraftment, rejection occurred at day 85 with severe aplastic anaemia. A second graft was performed with the same donor without engraftment and the patient died at day 18 of pneumonitis. A review of the literature is proposed and the ethical choices are discussed.

[Seminoma of testis. Analysis of failures and development of therapeutic strategies. Apropos of a Lyons series of 117 cases]. / Le séminome du testicule. Analyse des échecs et évolution des stratégies thérapeutique. A propos d'une série lyonnaise de 117 cas.

From Jan.61 to Dec.81, 117 patients with seminoma of testis were treated in the Leon Berard Centre, Lyon. All had undergone lymphography during investigation of possible extension, 19 were treated with 200 KV up 1966, 64 with Cobalt up to 1978 and 29 with photons x of 18 MV since that date. From 1979 adjuvant chemotherapy has always included cisplatinum. The 5 years survival rate was 95% of stage I (51/54 cases), 72% of stage II (26/36 cases) and 1/7 of stage III. Unsuccessful treatment of neoplasm was noted in 23 patients, in 80% of cases during the first two years and involving mainly pulmonary metastases. Three patients had mediastinal metastases while recovery surgery was possible in 4 cases. Three fatal iatrogenic complications were observed. Since the use of high energies, particularLy x beams of 18 MV there has been almost total absence of radic complications. Therapy now proposed is as follows: stage I: surgery plus radiotherapy; stage II A-B: surgery and irradiation avoiding mediastinum; stage II C and III: primary chemotherapy.

[Massive chemotherapy and purged bone marrow autograft in severe neuroblastoma. Preliminary results apropos of 5 cases]. / Chimiothérapie massive et autogreffe de moelle purgée dans les neuroblastomes graves. Résultats préliminaires à propos de 5 cas.

Massive chemotherapy with in vitro purged autologous bone marrow transplantation has benefited from better understanding of massive chemotherapy for solid tumors, and better search for bone marrow involvement; it may now be used for treatment of poor prognosis neuroblastomas. Authors report preliminary results of 5 cases (4 IV and 1 p III b stage of TNM classification) completely treated in one institution (Centre Léon-Bérard, Lyon, France). Three patients are in complete remission, and 2 have relapsed (median follow up: 18 months). Authors comment on these results.

Paraaortic lymphadenectomy is not necessary in the treatment of localized paratesticular rhabdomyosarcoma.

Paraaortic lymphadenectomy is routinely recommended to treat paratesticular rhabdomyosarcoma (RMS) because of the high incidence of lymph node involvement. Taking into account the effectiveness of chemotherapy to sterilize micrometastases and aiming to reduce short-term and long-term side effects due to lymph node dissection, the RMS Group of the SIOP decided to avoid lymphadenectomy in Stage I paratesticular RMS defined by (1) complete tumor removal with negative cord section and (2) negative pedal lymphangiography. A series of 19 children (mean age 5 years, 6 months), treated between 1971 and 1981, were analyzed. Eighteen of 19 patients received adjuvant chemotherapy, using vincristine, actinomycin, cyclophosphamide, singly or alternately with vincristine, Adriamycin (doxorubicin) every 3 weeks. Duration was either 18 months (7 cases) or 8 months (11 cases). Fourteen patients are in first remission with a follow-up of more than 3 years (median 5 years); three are disease-free 35, 23, and 20 months since diagnosis; two patients are alive without evolutive disease, 32 and 56 months after an abdominal relapse. Results obtained in this series demonstrate the ineffectiveness of systematic paraaortic lymphadenectomy in Stage I paratesticular RMS and the effectiveness of chemotherapy to eradicate occult micrometastases, which obviously may exist in paraaortic lymph nodes in spite of apparently normal lymphographic findings.

[Treatment, by 192-iridium curietherapy, of epitheliomas of the penis. Apropos of 36 cases]. / Traitement par curiethérapie à l'Iridium 192 des épithéliomas de la verge. A propos de 36 cas.

Since 1975, 36 patients with squamous cell carcinoma of the penis have been treated with 192 Iridium at the Centre Léon Bérard: 17 T1 lesions, 18 T2 lesions and one T3 lesion. The tumor was less than 4 cm in diameter in 31 cases. Two patients presented with local recurrences after local excision and/or external beam irradiation with 60 Cobalt. In 32 patients followed for more than one year, the rate of local control was 84% (27/32). Five local failures were controlled by subsequent salvage surgery. The rate of severe complications is 25% (8/32): 2 urethral stenoses, 4 necroses, and 2 severe fibrosis. Conservation of a functional organ was possible in 72% of cases (23/32). Amputation was necessary in the 5 patients with lesions of more than 4 cm, because of local failure or painful complications. Ten patients had palpable inguinal lymph nodes, which were found to be involved in 4 cases. Three were controlled by combined radiotherapy and surgery. Among patients off any lymphadenopathy at the time of diagnosis, only one subsequently developed an inguinal metastasis which was controlled by radiotherapy and surgery. The disease-free survival rate was 81% at 3 years (22/27) and 75% at 5 years (12/16). Only one patient died of carcinoma. Curietherapy with 192 Iridium is very suitable treatment for cancers of the penis less than 4 cm in diameter. In most patients, the quality of life will be better than with primary surgical amputation, because sexual function is preserved.

Massive BACT chemotherapy with autologous bone marrow transplantation in 17 cases of non-Hodgkin's malignant lymphoma with a very bad prognosis.

A group of 12 children and 5 adults, all with diffuse non-Hodgkin's malignant lymphoma (NHML), received massive chemotherapy regimens. The stages of the disease were as follows: 7 patients were in second complete remission; 6 in a progressive phase of the disease; and 4 in first complete remission which occurred late in the course of the disease. All patients received BACT (BCNU+aracytine+cyclophosphamide+thioguanine) or TACC (idem with CCNU) at different dose levels: 6/17 received 10 Gy total-body irradiation (TBI) after BACT treatment; 16/17 received autologous bone marrow transplantation (ABMT) previously stored in liquid nitrogen to combat the medullary effects of chemotherapy. Direct therapy-related deaths occurred in 4/17 patients (1 Aspergillus endocarditis; 1 Moskowitz syndrome; 1 veno-occlusive disease of the liver; and 1 Escherichia coli pneumopathy) and 6/17 patients relapsed between days 25 and 70 of treatment. Seven out of these 17 patients are still alive NED 102-900 days (mean, 475 days) after the beginning of therapy without receiving maintenance treatment. Massive chemotherapy could thus be the best treatment for NHML in relapse, but the high percentage of early therapy-related deaths is a strong limiting factor for patients before relapse.

[Changes in the management of osteosarcomas of long bones in the Léon Bérard Center, in the last twenty years ]. / Evolution du traitement des sarcomes ostéogènes des os longs au centre Léon Bérard au cours de vingt dernières années.

From 1958 to 1977, 68 patients with long bone osteosarcoma were treated with high dose radiation (greater than 80 grays) followed by amputation when needed. The survival rate free of disease is 33% at three years (23/68) and 31% at five years (20/64). Sterilization of the limb was obtained in 72% of cases (18/25 amputation specimens). Preservation of a functional limb often proved impossible because of the frequent occurrence of trophic disorders, especially fractures, after radiotherapy. The main benefit of primary irradiation is to avoid amputations that have become useless because pulmonary metastases have arisen. Surgical excision of pulmonary metastases can lead to prolonged survival (3 out of 6 patients alive free of disease at three years). As no conclusive randomized trials are as yet available, the benefits of adjuvant therapy (chemotherapy and/or radiotherapy) are still prospective. The present policy is to use adjuvant therapy in all cases, conservative treatment for small lesions, primary amputation in children under fourteen, and primary irradiation followed by systematic amputation one year later for extensive lesions in older patients.

[Dystrophy and necrosis following radiotherapy for maxillary cancer (author's transl)]. / Dystrophies et nécroses post-radiothérapiques dans le traitement des cancers du maxillaire supérieur.

About 10% of patients developed severe sequelae following radiotherapy, which had been associated with surgical treatment, even though they were, or appeared to be cured. Complications affected the skin and soft tissues (causing skin retraction, loss of substance, and sometimes trismus) and bone (necrosis required surgical treatment, and when there was associated cutaneous dystrophy, resulted in exposure of the bone and severe functional and esthetic problems). A critical study of the radiotherapeutic techniques used suggests that the dose given should be reduced, the fields modified, and Cobalt used in preference to electrons in most cases.

[Post-operative radiotherapy of hemisphere gliomas in the adult. A statistical study of 134 cases (author's transl)]. / La radiothérapie post-opératoire des gliomes hémisphériques de l'adulte. A propos d'une statistique de 134 observations

A series of 134 adults patient with hemisphere gliomas who received post-operative radiation after surgical excision, either by conventional radiotherapy or high energy radiation, between 1966 and 1972 in the Léon-Bérard Centre. Overall survival for grade I and II astrocytomas at two years was 15/29, or 51%. Overall survival for glioblastomas was 30/91, i.e. 33% at one year, and 3/91 or 3.3% at two years. High energy radiation gave slightly superior results to conventional radiotherapy. The best results were obtained with concentrated irradiation when two series of irradiation were possible : 8/17 at one year (47%). Analysis of the literature indicates that radiotherapy, whilst remaining controversial for grades I and II astrocytomas, is recognised to be useful by all in the case of glioblastomas. The authors favour the post-operative irradiation 6,00 to 6,500 Rads, localised) for grade I and II astrocytomas with pejorative characteristics and routin- post-operative irradiation for glioblastomas over a wide field taking in almost the entire brain. This may be spread (6,000 Rads) or in a "split course" (two series of 1,800 each). The latter technique has the advantage of a simple protocol, better adapted to lesions in which the final prognosis remains very poor. Finally, the indications for radiotherapy in the case of supra-tentorial ependymomas (3 cases) and oligodendrogliomas (6 cases) are presented, together with an analysis of the complications of radiotherapy for cerebral tumours.

[Postoperative radiotherapy of hemispheric glioma in the adult. A propos of 134 cases]. / La radiothérapie post-opératoire des gliomes hémisphériques de l'adulte. A propos d'une statistique de 134 observations

We are dealing here with a series of 134 hemispheric gliomas of the adult subject submitted to irradiation after surgical exeresis. The 2 years survival rate reaches 51 p. 100 for stage I and II astrocytomas (15/29) and 3,3 p. 100 for glioblastomas (30/91), the I year survival rate for the latter ones reaching 33 p. 100. The analytic study of medical literature lets appear that if roentgentherapy remains controverted in the case of stage I and II astrocytomas, it is recognized as useful, by all the authors, in the glioblastomas. Modalities and technique of the irradiation are object of an analytic study. Authors are favourable to post-operative irradiation stage I and II astrocytomas exhibiting pejorative features (focalized 6.000 to 6.500 rads) and to systematic post-operative irradiation in the glioblastomas over extended fields, either spreaded on irradiation (6.000 rads) or concentrated irradiation (two series of 1.800 rads). This latter technique has provided identical results as the spreaded on irradiation and represents a less heavy procedure. Mention is made of roentgentherapy in the supratentorial ependymomas (3 cases) and in the oligodendrogliomas (6 cases), followed by an analytic study of the complications consecutive to roentgentherapy of the encephalic tumors.