Respective roles of radiotherapy and surgery in the management of epidermoid carcinoma of the anal margin. Series of 57 patients.

The study of 54 patients treated curatively by irradiation with or without surgery is reported. The crude and cancer-specific five-year survival rates are 59.2 percent and 79.7 percent. Three patients were treated palliatively. The great variation in histologic type, clinical appearance, disease stage, and patient status justifies the definition of a treatment strategy using radiotherapy, surgery, or a combination of the two methods. T1 and T2 squamous- or basal-cell carcinomas are suitable for local excision followed by irradiation or for irradiation alone. T3 tumors and Bowen's disease should be treated by irradiation first. Verrucous carcinoma is suitable for local surgery followed by irradiation. Mucoepidermoid carcinoma and T4 tumors are suitable for preoperative irradiation and delayed surgery. The optimal radiation technique consists of delivering a dose of 40 Gy in 17 days by cobalt-60 with bolus and in combination with concomitant chemotherapy (5-fluorouracil and mitomycin C). Prophylactic irradiation of the inguinal area is recommended in all NO tumors except for T1 lesions and basal-cell carcinomas.

Results of postoperative radiation therapy in medullary carcinoma of the thyroid: a retrospective study by the French Federation of Cancer Institutes--the Radiotherapy Cooperative Group.

Between 1971 and 1989, 59 patients received external radiation therapy with a curative intent. There were 25 females and 34 males, ranging in age from 19 to 87. No patients had distant metastasis at the onset of treatment. The majority of patients had a total thyroidectomy (55/59), generally combined with neck dissection. Residual tumour was left in 11 cases, and 44 patients had positive cervical nodes. Using megavoltage radiotherapy, the whole neck and the upper mediastinum area were most often irradiated through a large anterior Y-shaped field without laryngeal shielding. The mean dose to the tumoral bed was 54 Gy. Dysphagia was observed in 32 patients (11, 17 and 5 scores were grade 1, 2 and 3, respectively). Dyspnea occurred in five cases and in two of these cases, it was considered to be severe. Local recurrences were noted in 18 (30%) patients, most of them occurring within the fields of irradiation. Parameters such as age, sex, total dose, irradiated volumes or cervical node enlargement did not modify the local control rate. The same conclusions can be drawn for distant failures. Thirty five patients are still alive and among them, 24 have no evidence of disease. The average length of survival is 70.5 months and is shortened by the occurrence of distant failures except in patients with bone metastases.

Cerebral metastases as first symptom of bronchogenic carcinoma. A prospective study of 37 cases.

Among the patients showing evidence of cerebral metastases without previously known cancer history, lung cancer has been found 37 times as the primary tumor in our institution. There were 34 men and three women and all but two were heavy smokers. Only one presented at diagnosis with thoracic symptoms but the chest radiograph was abnormal in 34. The histologic type of the primary tumor was obtained in 32 cases as a result of thoracic investigations and in five cases from metastatic tumor tissue. The primary tumor appeared to be non-small cell lung carcinoma in 26 cases and small cell lung carcinoma in 11 cases. These results show that patients treated with surgery (20 cases) have a better survival (median 10 months versus 4.5) than the others, and among surgically treated patients only those treated with bifocal resection (eight patients) are long-term survivors. Also, in four of six patients, objective regression of the neurologic symptoms was seen after radiation therapy alone. Central nervous system relapse was seen in 12 patients, but in none of the patients treated with postoperative radiation therapy. Conventional chemotherapy (11 patients) induced objective responses only in the small cell type and proved to be too toxic when used simultaneously with radiation therapy in inoperable patients.

[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.

Interstitial curietherapy in the conservative treatment of anal and rectal cancers.

Conservative treatment has become a valid alternative to radical surgery in most cases of cancer of the anal canal and in selected cases of cancer of the low rectum. In this strategy interstitial curietherapy has an appreciable role to play. The results of a series of 369 patients followed more than 3 years indicate that implantation of Iridium-192 is effective not as sole treatment but as a booster dose 2 months after a course of external beam or intracavitary irradiation. The dose delivered did not exceed 20 to 30 Gy and the implantations were always performed in one plane using either a plastic template or a steel fork. Three groups of cases must be considered: (a) among 221 patients with epidermoid carcinoma of the anal canal, the rate of death related to treatment failures was 20% and among the patients cured more than 90% retained normal sphincter function. (b) In 90 patients with T1-T2 invasive adenocarcinoma of the rectum, Iridium-192 was carried out after four applications of contact X ray therapy. The rate of control was 84%. (c) In 62 elderly, poor risk patients with T2-T3 tumor of the low rectum initially suitable for an abdomino-perineal resection, a tentative extension of the field of conservation was made using a split-course protocol combining a short course of external beam irradiation at a dose of 30-35 Gy in 10 fractions over 12 days and an Iridium-192 implant. The rate of death due to treatment failures was 14.5% and among the patients controlled 97% had a normal anal function. These results show that implantations of Iridium-192 may contribute to the control of anal and rectal cancers and may spare many patients a permanent colostomy, but the treatment requires great care in patient selection, treatment protocol, technical details, and follow-up. This treatment policy must be conceived as a team work of radiation oncologists and surgeons.

[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.

Radionuclide bone imaging in diaphyseal aclasis with malignant change.

Chondrosarcoma is a rare complication in hereditary multiple exostoses. The six patients in this study have had a complete follow-up and constitute the largest group of such cases to have been studied so far. Five patients had histologic evidence of malignancy. Since histologic examination can be very difficult, any other diagnostic features, may it be clinical, radiologic, or scintigraphical, should be taken into account for early surgical treatment. Bone scintigraphic examination is a valuable adjunct to early diagnosis of malignant change by showing highest uptake in malignant areas. It is also very useful for posttherapeutic follow-up.

[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.

Conservative treatment of early carcinoma of the breast: significance of axillary dissection and iridium implant.

One hundred and ninety five patients with T1T2 less than 3 cm N0 infiltrating carcinomas of the breast have been treated between 1973 and 1982 with local excision followed by cobalt irradiation and iridium boost. One hundred and sixty five underwent an elective axillary dissection. The overall survival at 5 years is 87% and the NED survival 81%. The size of the tumor on the mammogram and on the operative specimen is of significant prognostic value. At 5 years the probability of local relapse in the breast is 4% and the probability of axillary recurrence is 1.2% after axillary dissection. Comparison of these results with those of an historical group of 300 patients treated between 1950 and 1973 indicates an improvement in the local control with good cosmetic results and no obvious change in axillary recurrence and overall survival.

[Role and aspects of lymphography in juvenile chronic polyarthritis]. / Place et aspect de la lymphographie dans la polyarthrite chronique juvénile.

The authors report two cases of Still's disease with unusual presentation, characterized by important paraaortic lymphatic nodes. The findings of the lymphography could not distinguish between Hodgkin's disease, lymphoma, or inflammatory hyperplasia. Lymphography is usually of little interest for the diagnostic of Still's disease. However the knowledge of such misleading aspects is important when unusual clinical manifestations lead to perform a lymphography.

[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.

A new approach to the management of epidermoid carcinoma of the anal canal.

Until recently most squamous cell carcinomas of the anal canal were treated by radical surgery. Radiation therapy was only considered for palliation in case of inoperable tumors. Important progress has been made in the knowledge of the natural history of the disease and in the field of radiotherapy. Anal canal squamous cell carcinoma should not be treated any longer by the same procedure as adenocarcinoma of the lower rectum, because both these diseases differ markedly. Multimodality therapy with radiotherapy as first approach has been considered. This series of 121 cases treated since 1971 and followed more than three years suggests that three protocols based on irradiation followed or not by surgery should be used according to the extent of the disease. Of the 72 patients with resectable tumor, the five-year survival rate was 65%. Three-quarters of the patients cured had normal anal function. The rate of death from cancer was 18%. The method requires an accurate assessment of the extent of the tumor and of its pelvic lymphatic spread. Great care must be taken in planning treatment in a close cooperation between radiotherapist and surgeon.

[Cancer of the rectum: current trends in radiotherapy in conservative treatment]. / Cancer du rectum: perspectives nouvelles de la radiothérapie dans le traitement conservateur.

Conservative treatment of rectal cancer by intracavitary irradiation (Philips contact x-ray therapy followed or not by Iridium implant) is only applicable to tumours which are thought to have no lymphatic spread. A strict selection of cases is compulsory, especially with regard to the probability of lymph node involvement (degree of histological differentiation, degree of infiltration of the rectal wall, absence of palpable pararectal metastatic lymph nodes). After treatment, follow-up must be performed methodically. Moreover, in patients not older than 55, mesenteric and perirectal lymphadenectomy must be considered. At the Centre Léon Bérard (Lyon), 231 patients followed more than 5 years have been treated. The 5-year and 10-year survival rates are respectively 57 per cent and 74 per cent. The rate of local failure is 5.2 per cent. The rate of death from cancer at 5 and 10 years is 10 per cent. However intracavitary irradiation is only applicable in 10 to 15 per cent of rectal cancers. A new conservative approach has been worked out. It consists of preoperative external beam irradiation with Cobalt 60 (30 Gy in 12 days) followed 2 months later, according to the residual disease, either by radical surgery of Iridium implant. Applied to poor risk, patients this method can spare many of a permanent colostomy, without jeopardizing their chances of cure (27 cases, median age: 77 years).

[Endolymphatic curietherapy by lymphography with labelled lipiodol in Hodgkin's disease. A report on 408 cases (author's transl)]. / La curiethérapie endolymphatique par lymphographie au lipiodol marqué dans la maladie de Hodgkin. 408 observations.

The results of 373 lymphography examinations with radioactive lipiodol, conducted in 408 patients with Hodgkin's disease for diagnostic and prophylactic therapeutic purposes, during investigations carried out from 1966 to 1973 are analyzed. Tolerance was always excellent, especially from the hematological point of view. The efficacy of the procedure can be assessed by the fact that there were only 6% of failures (21/373) in glandular regions irradiated in this way for prophylactic purposes. Relapses occur more frequently in the inguino-iliac and lumbo-aortic regions than in the pelvic chains which were perfectly protected. This technique also enables both pelvic irradiation and ovarian protection in young women without any risk of failure. The procedure is particularly indicated in the following cases: supradiaphragmatic stages I and II, whatever the sex, and stage III especially in women. In sub-diaphragmatic stages I and II, it allows, in favourable cases, the ovarian function in women to remain intact by limiting external irradiation to invaded regions only.

[Surgically treated supratentorial gliomas in the adult. Favourable action of a podophyllin derivative (VM 26) administered alone (author's transl)]. / Gliomes malins supratentoriels opérés chez l'adulte. Action favorable d'un dérivé de la podophylline (le VM 26) administré seul.

The action of VM 26 on cerebral glioblastomas was suggested by studies of phase II or protocols in which the drug was used in association. The randomised protocol presented here, involving 10 treated subjects and 11 controls, showed that VM 26 was active in terms of the duration of survival of patients undergoing surgery for a glioblastoma. The mean survival was 16.4 months as against 9.6 months in the controls (statistically significant difference at p less than 0.05). This activity would tend to characterise the drug as one of the essential factors in the chemotherapy of all malignant gliomas, in particular since it is itself free of all haematological complications, even at high doses, and causes scarcely any allergic problems.