Conservative treatment by irradiation of epidermoid cancers of the anal canal: prognostic factors of tumoral control and complications.

UNLABELLED: We analyzed in a retrospective series of patients treated by conservative irradiation for an epidermoid cancer of the anal canal (ECAC) the prognostic factors of locoregional control (LRC), survival, late severe complications (LSC), and sphincter conservation (SC). METHODS AND MATERIALS: From 1976 until 1994, 118 patients presenting with an ECAC were conservatively treated (mean age, 65 years). According to the 1987 International Union Against Cancer (TNM) classification, they were: 19 T1, 70 T2, 22 T3, 7 T4, 94 N0, and 24 N1-3. The treatment started with external beam irradiation (EBI) (36 Gy in 3 weeks or 45 Gy in 5 weeks). Concomitant chemotherapy (5-fluorouracil and mitomycin C) was delivered to 31 patients. Two months later, a boost of 20 Gy was delivered by interstitial 192Ir brachytherapy to 101 patients and EBI in 5. Twelve other patients had an abdominoperineal resection (APR). The mean follow-up was 6 years. RESULTS: At 5 years the overall survival was 60%, and specific survival (SS) was 75%; it was 94% for T1, 79% for T2, 53% for T3, and 19% for T4. In multivariate analysis, tumor size (> or = 4 cm), node involvement, and no response to the EBI were factors of poor prognosis for SS. Thirty-two locoregional recurrences occurred of which 21 were local recurrences in the 106 patients treated by a conservative schedule. Only tumor size and response to the EBI were prognostic factors on multivariate analysis for local and LRC. A total of 17 patients presented with LSC (Grade 3, 16 patients; and Grade 4, 1 patient), which was treated by APR in 4 patients and colostomy in 11 (of which 7 were definitive). The only significant prognostic factor for LSC in the multivariate analysis was the total extrapolated response dose of irradiation. The definitive rate of SC after conservative treatment in cured patients was 100% for T1, 82% for T2, 58% for T3, and 100% for T4. Since 1989, improvements of the technique have allowed reduction of the LSC in maintaining the same local control. CONCLUSION: The results of this series are similar to those of the literature. The confirmation of pretherapeutic prognostic factors related to response to the treatment should allow us to adapt the therapeutic intensity for each case to obtain better tumor control, with as few sequelae as possible, to yield a better rate of SC.

[Massive transfusion in cancer surgery. A study of the survival of 21 patients]. / Transfusions massives en chirurgie carcinologique. Etude de la survie de 21 malades.

In a retrospective study over 5 years, the evolution of 21 patients who received a massive blood transfusion during a carcinological surgery was analyzed. In this type of surgery, the frequency of massive blood transfusion is 0.28% and affects 2.5% of the patients transfused. In half of the cases, surgery was performed to resect an ovarian cancer. The overall death rate, related to the importance of the blood transfusion, is high: 38% (8 patients out of 21). Among the patients who survived (13), the actuarial survival is low: 10 deaths from local or metastatic disease with a mean survival of 12 months, suggesting that the use of massive blood transfusion was related to the tumoral aggressiveness and to the severity of the deepseated malignant disease.

[Identification and information on patients transfused between 1980 and 1985 at Alexis Vautrin Center]. / Identification et information des transfusés de 1980 à 1985 au Centre Alexis Vautrin.

In 1993, in Centre Alexis Vautrin, we took quite easily the census of 3,170 patients transfused between 1980 and 1985. In our institution, the systematic long-term follow-up of patients treated allowed to select rapidly the patients alive and to ask family doctors to inform and propose screening tests for a possible contamination by HIV and HCV viruses. Out of 802 patients alive, 703 accepted the tests. No contamination by the AIDS virus was detected. Conversely, the survey evidenced positive serology for the virus of Hepatitis C in 16 cases (2.4%).

Epidermoid carcinomas of the floor of mouth treated by exclusive irradiation: statistical study of a series of 207 cases.

PURPOSE: Our aim was to study the results and the complications of this series of 207 patients treated from 1976 to 1992 and to compare them with the results of the literature. MATERIAL AND METHODS: The treatment consisted of a combination of external beam irradiation (EBI) (to the tumor and the node areas) and complementary brachytherapy to the primary tumor in 105 cases. In 102 cases, brachytherapy only was delivered to the tumor with or without neck dissection of the node areas. The brachytherapy was performed mostly with the hairpin technique in the beginning (in 61 cases) and subsequently the plastic tube technique with iridium wires. The dosimetry followed the Paris system rules. There were 41% T1, 48% T2, 8% T3, 2% T4 and 1% Tx with 83% N0, 12% N1, 3% N2, 2% N3. Ninety-one percent of patients were male and 9% were female. RESULTS: The local control at 5 years is 97, 72 and 51%, respectively, for T1, T2, T3. The specific survival (without the patients dead of intercurrent disease or second cancer) was 88, 47 and 36%, and the overall survival at 5 years was 71, 42 and 35%. Of note, approximately one third of patients died of intercurrent disease or second cancers (70 patients = 34%). Significant factors that can influence the results are: for local control, the size of the lesion T1/T2/T3 (p < 0.0001); for the locoregional control, the absence of node involvement. The following factors are not significant: age and sex (age significant for survival). The significant treatment factors are the safety margin (p < 0.0003), brachytherapy only on T for T2N0 (p = 0.01). A total duration of treatment of less than 50 days is also significant. The spacing and the total dose (higher dose for large tumors) were not found to be significant. The complications were classified into four grades: grade 1, 17% (median healing, 2 months for soft tissue complications and 5 months for bone complications); grade 2, 12%; grade 3, 6% (frequently requiring surgical resection); grade 4, 0.5% (death, one case). In this series, for the complications, the dose rate, the spacing and the total dose were found not to be significant. CONCLUSION: Carcinomas of the floor of mouth treated by exclusive irradiation have a rather good prognosis and the number of grade 2 and 3 complications remains acceptable. Exclusive brachytherapy is preferable to the combination of EBI plus brachytherapy for T1T2N0.

Brachytherapy for lower lip epidermoid cancer: tumoral and treatment factors influencing recurrences and complications.

From 1972 to 1991, 237 patients with squamous cell carcinoma of the lower lip were treated by exclusive LDR brachytherapy (192Ir). There were 158 T1, 61 T2, 17 T3 and 1 T4 with 231 N0, 3 N1 and 3 N2 patients. The actuarial values at 5 years for local and regional controls, overall and specific survivals were 95%, 91%, 74% and 91%. Salvage treatment increased local control up to 99% and regional control to 94%. No heterolabial recurrence has been observed since the entire lip is treated, even for small tumors. The regional control depends closely on the thickness of the labial tumor (> or = 1 cm, p < 0.0001). The healing of treatment-induced mucositis is sometimes delayed for thick tumors (> or = 1 cm, p = 0.015). Late complications are not related to tumoral thickness but to the treated thickness (> 1.4 cm, p = 0.018) and particularly to the thickness of normal tissue included in the 85% isodose (treated thickness - tumoral thickness > 0.4 cm, p = 0.025). The use of a leaded protection and low linear radioactivity wires (< 2 mCi/cm, < 8.6 muGy/h.m2/cm) especially for large target volumes is required to lessen late complications. Based on this review, we advocate exclusive brachytherapy for small and intermediate tumors, with elective bilateral submaxillary and submental dissection for thick, high grade or commissure tumors. Simple recommendations are made to assure quality of the brachytherapy treatment.

Salvage irradiation by brachytherapy of velotonsillar squamous cell carcinoma in a previously irradiated field: results in 73 cases.

PURPOSE: The salvage brachytherapy performed in patients presenting velotonsillar carcinoma in a previously irradiated field is evaluated in terms of local control, complications and survival. METHODS AND MATERIALS: Between 1976 and 1990, 73 patients presenting with velotonsillar squamous cell carcinoma in a previously irradiated area were treated at Center Alexis Vautrin with brachytherapy along using an 192Ir implant (afterloading technique) with curative intent. According to the UICC 1987 TNM classification, there were 45 T1 N0, 20 T2 N0, one T3 NO, one T3 N2 and six Tx Nx. RESULTS: The 5-year actuarial local control for T1 N0 and T2 N0 are 80% and 67% respectively. The regional relapse rate was 10% in both groups. Grade 2 complications occurred in 13% of patients and these were neither related to the volume treated nor the dose rate. There were no Grade 3 or 4 complications. The 5-year specific survival is 64%, with a plateau after the 5th year, but the 5-year overall survival is only 30%. Fourty-two percent of the patients in this series died from another carcinoma. All but two of these were related to continued alcohol and tobacco intoxication. CONCLUSION: We conclude that brachytherapy alone (60 Gy) is optimal treatment for patients presenting with velontonsillar carcinoma in a previously irradiated field. The greatest challenge is the screening of these patients and the prevention of subsequent head and neck cancers. Recognizing the fact that these patients are at high risk for subsequent malignancies of upper aerodigestive tract, lung and esophagus, close surveillance is necessary for: (a) early diagnosis and prompt treatment; and (b) development of prevention strategies of field cancerization.

[Natural history and development of bone metastasis. Apropos of 429 cases]. / Histoire naturelle et évolution des métastases osseuses. A propos de 429 observations.

The records of 429 patients seen at the Centre Alexis-Vautrin in 1979 and 1980 with bony metastases were retrospectively reviewed to assess their natural history and survival. Breast was the location of primary lesion in 140 patients (32.6%), lung in 95 patients (22.1%) and prostate in 33 patients (7.7%). The primary tumor was of unknown origin in 42 cases (10.9%). The median survival from time of diagnosis was 5 months. Two and 5-year survival rates were 17.5 and 5.1% respectively. According to the nature of the primary tumor, 2 and 5-year survival periods for bony metastases were 36.4 and 7.9% in breast cancer, 33.3 and 15.2% in prostatic cancer, 4.3 and 2.1% in metastases of unknown origin, 2.1 and 0% in pulmonary carcinoma. Multivariate analysis revealed four factors to be of prognostic significance for survival: the nature of the primary tumor, the absence of local relapse, the disease-free interval and the absence of metastases in other sites. Patients with hormone-sensitive lesions or slowly-growing tumors had a better prognosis.

[Treatment of 95 non-seminomatous germinal tumors of the testis]. / Etude du traitement de 95 tumeurs germinales non séminomateuses du testicule.

A retrospective analysis of 95 treated nonseminomatous germinal testicular tumors is made. The primary treatment consisted of orchidectomy with high ligation of the cord. A histological study disclosed 53 embryonal cell carcinomas (56%), 21 chorioepithelionas (22%), 7 teratocarcinomas (7%) and 14 complex composite tumors which were predominantly dysembryomatous (15%). Forty-three patients were classified as stage I, 13 as stage II and 39 as stage III. Retroperitoneal pelvic and peri-aortic lymphadenectomy performed in patients with a testicular dysembryoma classified as stage I, had a survival of 70% 5 years postoperatively versus only 46 when treated solely with radiotherapy. Stage III cases with choriocarcinoma did not survive 3 years. These results are compared with those reported in the literature. The presently applied therapeutic scheme is described.

[Is bone scan useful in patients with breast cancer localized on the basis of clinical examination. 143 cases (author's transl)]. / Faut-il faire la scintigraphie osseuse systématique dans les cancers du sein apparemment localisés? A propos de 143 cas.

The authors present 143 cases of breast carcinoma T1 and T2, N0, N1, N2 and N3 without clinical signs of bone metastasis. They study the value of bone scintigraphy with technetium 99m labelled diphosphonates. One hundred and twelve patients had normal bone scans; 31 patiets showed abnormal fixation sites: in 23 (16%) benign bone lesions explained the increase of the bone radioactivity, in 8 cases, scintigraphy was considered to be consistent with diagnosis of bone metastasis. Metastasis has been proved in only 3 cases within a period of 2 years. The detection rate cannot be better than 5,6 per cent. Considering 50 per cent at least of these patients will eventually develop bone metastasis, the false negative rate will be about 45 per cent. Routine bone scan does not seem to be useful for patients with T1 and T2 breast cancer.