Radiation therapy of skin carcinomas: results of a hypofractionated irradiation schedule in 675 cases followed more than 2 years.

Six hundred and seventy-five cases of cutaneous epidermoid carcinomas of the face (excluding the lips, ears and eyelids) were treated with superficial irradiation therapy according to an original dose and time schedule (3 fractions of 1020 R over 14 days), with correction for RBE. The reference dose was always set at the deepest portion of the tumor (100% isodose including the lesion) and surface dose was limited to 125% of the depth dose. The energy used varied according to the thickness of the tumor, and the size of the irradiation fields according to the diameter of the tumor. All other parameters remained constant. The results after a minimum follow-up of 2 years show that the failure rate was low (less than 4%) and could be corrected in 85% of cases. Ninety per cent of recurrences appeared within 3 years; they were central and most frequently observed in nasal locations and basal cell carcinomas. Complications were rare (fewer than 3% of cases), and the majority were cured by medical treatment. Cosmetic results were satisfactory in over 90% of cases. The method used for expression of the dose permits a clear and coherent interpretation of the results: complications and sequelae were closely correlated with the irradiated surface and volume. The hypofractionated irradiation protocol described in this paper offers a simple, ambulatory method for the treatment of cutaneous epidermoid carcinomas of the face which have a particularly high incidence among the elderly. The majority of patients can be treated in this way.(ABSTRACT TRUNCATED AT 250 WORDS)

[Computerized medical records. The experience of the François Baclesse Center]. / Le Dossier Médical informatisé. L'expérience du Centre François Baclesse.

Information regarding the patient needs to be known before all consultations or treatment. There may only be one medical file in which this information is contained and hence there are problems regarding storage and transport which slow down the diagnostic process and treatment. The replacement of this file on paper by a completely computerised record file (observations, laboratory results, hospital reports) allows instantaneous consultation and access to such a record. For the last two years the traditional paper file has been replaced by more than 130 terminals distributed throughout this establishment. Additional functions may be added (statistics, internal information, etc...).

[A systematic radio-surgical combination in the treatment of sarcoma of soft tissues in adults. Results in 106 cases at the Centre François Baclesse]. / Association radio-chirurgicale systématique dans le traitement des sarcomes des tissus mous de l'adulte. Résultats dans 106 cas au Centre François Baclesse.

Based on a series of 143 cases of soft tissue sarcomas, including 106 cases treated curatively, the author stresses the importance of surgical resection with frozen section histological control, systematically combined with radiotherapy. Even when resection is complete, the frequency of loco-regional recurrences in all published series shows that neoplastic cells were already present around the resection site. Consequently, since 1972 at the Centre François Baclesse, whenever possible, surgery is preceded by concentrated regional irradiation (2 sessions of 6.50 Gy at 48 hour's interval) and postoperative complementary radiotherapy is always performed regardless of the quality of the resection 3 weeks after the preoperative irradiation. The dose is limited to a total of 50 Gy when the resection is complete and is increased to 60 to 70 Gy in the zones of doubtful or incomplete resection. This postoperative radiotherapy is associated with 5 injections of actinomycin D during the first sessions, but no adjuvant chemotherapy such as cyvadic is administered routinely. Under the conditions of treatment, the 5-year results obtained in 106 cases were as follows: local recurrences: 12.4%, metastases: 26%, survival rate: 76%. When the surgical resection was complete (62 cases), the 5-year local recurrence rate was 1.5% with 9% metastases and 92% survival. Metastases were related to factors of high malignancy which are beginning to be more clearly defined. These forms may benefit from intensive combination chemotherapy.

Osteosarcoma of the limbs. Report of the EORTC-SIOP 03 trial 20781 investigating the value of adjuvant treatment with chemotherapy and/or prophylactic lung irradiation.

The European Organization for Research on Treatment of Cancer (EORTC) trial 20781, concerning osteosarcoma of the limbs is reported. After definitive treatment of the primary tumor with amputation or irradiation, adjuvant treatment was given, randomized into either 9 months of chemotherapy according to a modified Rosen schedule, or elective bilateral lung irradiation of 20 Gy, or 3 months of chemotherapy followed by lung irradiation. The 4-year disease-free survival and total survival were 24% and 43%, respectively, with no difference between the treatment arms. In the radiotherapy arms the lung metastases were more frequently suitable for surgical treatment. The survival of patients with either tibia localizations or higher age was somewhat better. Local recurrences occurred in 16% of patients, 50% of them with distant metastases. The trial was executed from 1978 to 1983; 205 patients were evaluable and eligible, and three toxic deaths occurred in the chemotherapy arms. Elective lung irradiation provided the same survival as the adjuvant chemotherapy given in that time.

[Radiotherapy of sarcomas of the soft tissue in the adult]. / Radiothérapie des sarcomes des tissus mous de l'adulte.

Clinical experience has proved henceforth that radiotherapy must be considered as an integral part of the treatment of adult soft tissue sarcomas. When combined with surgery, it considerably reduces the local recurrence rate and increases the long term cure rate to about 70%. Such results can be achieved with the minimal impeding sequellae when the dose of irradiation is adjusted following the quality of the surgical excision. A dose of 50 Gy is sufficient when no microscopic tumoral foci are left in the tumor bed by the surgeon. It must be higher when it is not the case. The residual metastatic risk is about 30%. We begin to know better which factors are linked to this risk. Clinical research is under way to assess the value of adding chemotherapy in the protocol of high risk patients.

[Combination of anthracyclines with radiotherapy. Value and problems]. / Associations des anthracyclines à la radiothérapie. Intérêt et problèmes.

Association between radiotherapy and anthracyclines (especially adriamycin) early showed major toxicity on critical normal tissues so that its antitumor activity was concealed. This toxicity proved to be acute toxicity, recall phenomenon and cardiac toxicity. Clinical and experimental studies showed synergistic effect when drug and radiation are administered concomitantly and additive effect in sequential administration. So concomitant association must be rejected. The main point is the time interval between adriamycin injection and radiotherapy (at least seven days). These conditions are respected when alternating treatment schedule is applied: radiation split courses are integrated between two chemotherapy cycles including adriamycin. At this time new anthracycline analogs were not associated to radiotherapy.

[Intraoperative abdominopelvic radiotherapy by single dose electrons]. / Radiothérapie abdomino-pelvienne per-opératoire par électrons à dose unique.

Thirty-four patients received, during laparotomy, a 15-20 Gy localized irradiation from a 10-13 MeV beam of electrons supplied by a linear accelerator and focalized by means of a localizer especially designed for this purpose. This technique is indicated for localized residual tumours of the pelvis and intra-operative irradiation of the lumbar aorta, as part of a chemo-radiotherapeutic programme in patients with advanced cancer of the cervix. It is too early to evaluate the medium-term results, but the technique is very well tolerated immediately.

Local control and survival in soft tissue sarcomas of the limbs, trunk walls and head and neck: a study of 113 cases.

One hundred thirteen patients with soft tissue sarcomas of the limbs, trunk walls, and head and neck have been treated at the Centre François Baclesse since 1972. Of these, 89 histologically confirmed patients were treated with a multimodality treatment protocol. Treatment policy was designed to use each treatment method as efficiently, economically and conservatively as possible: preoperative irradiation at moderate dose to a large volume (6.5 Gy, 2 sessions, 48 hr interval); surgery 48 hr after the last preoperative irradiation; surgical excision was guided and verified intra operatively by the pathologist (with frozen sections); postoperative irradiation aimed at sterilizing all residual isolated and radiosensitive tumor cells, possibly scattered throughout the anatomical region. The total dose is brought to the equivalent of 50 Gy (preoperative dose included). This dose was increased to 60 or even 70 Gy to a restricted volume, when limb conservation was sought, but tumor foci too large for total resection without amputation; actinomycin was added to the first five postoperative irradiations. The results at 5 years were as follows: local recurrence rate, 13.6%; metastatic rate, 28%; survival rate, overall (113 patients,) 65.6%, curative series (89 patients), 75%. When the surgical excision of the primary tumor was histologically complete (54 patients) the local recurrence rate was 1.9%, the metastatic rate 11.6%, and the survival rate 89.6% at 5 years.

[Cancer registry of Calvados, hospital registry of the François- Baclesse Center and mortality statistics: comparisons]. / Registre des cancers du Calvados, Registre hospitalier du Centre Francois-Baclesse et statistique de mortalité: comparaisons.

Incidence rates of the cancer registry of the department of Calvados were compared, by site and by age group, with those obtained from the cancer registry of the comprehensive cancer center in Caen, concerning the population of the department of Calvados. In males, these rates are approximately similar for head and neck sites; for the hospital registry they are 50% of those recorded by the population registry for lung cancer, and 30% for prostatic cancer. In females, the all-sites rates are nearly identical for the youngest age groups and 50% for the older. They are not significantly different for digestive cancer, and 75% for cervix and breast cancer. The incidence rates of both registries were compared with mortality rates. They indicate mortality rates which appear relatively high for the pancreas, and they show imprecisions for the uterus and head and neck (pharynx-larynx) sites.

Combined radiotherapy-chemotherapy for early stages non-Hodgkin's lymphoma: the 1975-1980 EORTC controlled lymphoma trial.

Patients with stage I and II non-Hodgkin's lymphoma (NHL) are considered to have a relatively good prognosis. For this reason, they are seldom referred to specialized centers and the accrual of such patients in controlled studies is limited. Therefore, significant studies of homogeneously treated patients are difficult to collect and the management of these patients remains controversial. Some patients do very well after treatments with minimal toxicity while others require a much more aggressive approach. The Radiotherapy-Chemotherapy Group of the EORTC carried out its second controlled trial on patients with stage I and II NHL from 1975 to 1980. Its first aim was to assess the prognostic value of histologic classifications independently of treatment. The second aim was to compare two therapeutic options within each stage. In stage I, 124 patients were randomized to receive extended field radiotherapy (RT) either with or without adjuvant cyclophosphamide, vincristine prednisone (CVP) chemotherapy (CT). Relapse-free survival (RFS) was higher in patients who received adjuvant CVP but the total survival rates were not different. The RFS was lower in patients with diffuse than in those with follicular architectural histologies; in the former, RFS was not influenced by adjuvant CVP. Those patients who underwent a staging laparotomy had a higher 5-year total survival (TS) independent of the histologic type. Fifty-six stage II patients were included and extended field was randomized versus total nodal irradiation. Subsequently, adjuvant CVP was given to all patients. Results are good in follicular histologies but the advantage for total nodal irradiation is not significant. In diffuse histologies, results were unsatisfactory in both arms; a new therapeutic strategy was designed in which RT and CT are alternated and has been successfully tested in a pilot study.

Radiotherapy as an integrated part of the treatment of soft tissue sarcomas.

A considerable improvement in the prognosis of soft tissue sarcomas in the adult has been obtained with a treatment schedule combining surgery and routine radiation therapy (possibly preoperative and certainly postoperative); local recurrences, the predominant element in the natural history of the disease, have become very rare and limb function is generally maintained. Metastatic risk presents the major problem, and in our series spread of the disease remained uncontrolled in 25% of cases. Further research is required in this area, and a better definition of the risk factors, especially with regard to histology, is needed. We suggest that the possibility of reinforcing treatment of those histological forms at high metastatic risk by the introduction of multidrug therapy after local treatment be investigated. Such studies can only be effectively conducted within the framework of a multicenter collaborative controlled clinical trial.

[Bilateral lung irradiation as adjuvant therapy in osteogenic sarcoma ]. / Place de l'irradiation pulmonaire bilatérale dans le traitement adjuvant des sarcomes ostéogènes.

Bilateral lung irradiation as well as chemotherapy are still controversial in the "prevention" of pulmonary metastases from osteosarcomas. This paper presents theoretical and experimental evidence in support of such an irradiation. Doses which can be tolerated by the normal lung are recalled. Data from clinical experience is analyzed and the optimal modalities of irradiation are described. Confirmation of the presumptive effectiveness of radiation therapy can be obtained only through controlled trials such as the one which is ongoing at the EORTC.

[Frequency of complications and radiotherapeutic progresses in Hodgkin's disease (author's transl)]. / Fréquence des complications et progrès radiothérapiques dans la maladie de Hodgkin.

Two categories of iatrogenic effects are observed in Hodgkin's disease: the radiotherapeutic loco-regional complications; the systemic effects in which the long term carcinogenic risk is particularly important to consider. The first category can be avoided by the technical improvements which are steadily achieved. The second category can be minimized with a good therapeutic strategy in which the magnitude and intensity of the treatment are matched to the severity of each anatomical and clinical presentation.

The pathologist's role in a multidisciplinary approach for soft part tissue sarcoma: a reappraisal (39 cases).

A combined treatment modality of radiotherapy, surgery, and monochemotherapy in 39 cases of soft tissue sarcomas is presented. The 39 patients presented initially with local disease only, without evidence of metastases. At the end of the surgical procedure the adequacy of the excision had been evaluated by the pathologist. Surgical procedure was complemented by systematic radiation therapy. The overall recurrence rate was 7.7%; the overall incidence of metastases 31%. In the group in which adequate excision had been obtained, no loco-regional recurrences were obtained, survival was significantly better, and the incidence of metastases was lower than in group in whom adequate excision could not be obtained. The importance of two criteria was stress: the depth and the character of the margins of the tumor which cannot be considered separately. The results suggest that there is a correlation between the general and loco-regional malignancy of soft tissue sarcomas.

[Multidisciplinary treatment of soft tissue sarcomas: an improvement in prognosis (author's transl)]. / Sarcomes des tissus mous: progrès thérapeutiques par l'application d'un protocole pluridisciplinaire.

The results obtained in the treatment of 45 cases of soft tissue sarcomas are presented. All cases were reviewed and classified according to the modern criteria of malignancy. The treatment schedule comprised: (1) preoperative irradiation: 2 sessions of 6.50 Gy in 48 hours, target volume: whole limb segment; (2) surgical excision 48 hours later with systematic intraoperative histologic verification, until healthy tissue margins are obtained; (3) postoperative irradiation: 3 weeks later delivering a cumulative total dose of 50.00 Gy to the preoperative volume and 60.00 - 70.00 Gy to a reduced volume encompassing the surgical region with protection of vascular axes where possible; (4) chemotherapy: Actinomycin D 0.3 mg/m2 half and hour before the first 5 sessions of postoperative irradiation; (5) bilateral lung irradiation: 4 sessions of 3.75 Gy in 7 days to the whole chest. The results were as follows: local recurrence rate was 9.5 per cent at 5 years. In 21 cases in whom surgical excision was deemed histologically adequate, no recurrences was seen at 3 years (minimum follow-up). Survival at 5 years was 77 per cent. Deaths were due to metastatic spread, especially to the lungs. These results show an improvement as compared with historical series. New progress should be sought in combining a more aggressive type of chemotherapy for cases with high metastatic risk.

[Combined radiotherapy and chemotherapy: pulmonary side effects (author's transl)]. / Effets des associations radiothérapie-chimiothérapie sur le parenchyme pulmonaire.

Systemic chemotherapy and lung irradiation have very similar effects on lung tissue. Several mechanisms are involved, mainly: --cytotoxic effects on lung cells (type II pneumocytes, capillary endothelial cells, and connective tissue); --enhancement of infection; --hypersensitivity and auto-immune phenomena. Acute pneumonitis or chronic lung sclerosis develops which may or may not be compatible with life, depending on the lung volume involved and the clinical course. These effects are dose dependent for radiotherapy, and for most of the chemotherapeutic drugs. In some cases however, the dose-effect relationship is not clear, especially with some drugs such as methotrexate, and sometimes with radiotherapy even when it can be assumed that there is no mistake in dose calculation. It must be stressed that we will lack basic knowledge on the pharmacokinetics and actual concentration of drugs in lung tissue. Additive or supra-additive effects are likely when chemotherapy is combined with lung irradiation, but current relevant data does not allow any firm conclusions to be drawn on the quantitative changes resulting from the association. Prevention of lung complications is however possible if the tolerance doses and the optimal distribution of each agent with time are respected. Combined lung irradiation and bleomycin administration must be avoided.