[Retrospective analysis of 108 ductal carcinomas in situ of the breast treated by radiosurgery association]. / Analyse rétrospective de 108 carcinomes canalaires in situ mammaires traités par association radiochirurgicale.

PURPOSE: To evaluate survival and prognostic factors of 108 patients with clinically or mammographically detected ductal carcinoma in situ (DCIS), treated from 1980 to 1996 by complete local excision followed by external irradiation. PATIENTS AND METHODS: The median age was 51 (range 37-80). All the patients underwent surgery consisting of a wide resection of the mammary gland harbouring the tumour. The surgical specimens were sent to the pathologists to get information on histology and margin clearance; all the slides were reviewed by one of us to assess the tumoral diameter. External beam therapy was delivered within 8 weeks after surgery. The prescribed irradiation dose was 50 Gy in 25 fractions to be given in 5 weeks. The median duration of follow-up was 93 months (range 40-173). RESULTS: There were nine patients with local recurrence (8.3%); three patients had local recurrence of DCIS and six patients developed invasive breast cancer. The treatment of local recurrence consisted of mastectomy with or without axillary dissection (eight cases) and quadrantectomy (one case). The 5-year and 10-year ipsilateral recurrence-free rate was respectively 92 and 89%. The 10-year cause specific survival was 100%. In univariate analysis, size>or=10 mm, age<45 years old and margin status were significant P=0,02, P=0,03, P=0,005; margin status was significant in multivariate analysis (P<0,02). CONCLUSION: These results are in keeping with those of the literature. They could be improved by the mass screening campaign, which is going on since January 1990 among women aged 50-74 years.

Transient metabolic changes observed with proton MR spectroscopy in normal human brain after radiation therapy.

PURPOSE: To observe the time course of the proton magnetic resonance spectroscopy (1H-MRS) variations due to radiation therapy on normal human brain. METHODS AND MATERIALS: We followed 11 patients receiving an exclusive external radiation therapy for brain tumor for 8 months. They underwent proton MRS scans before any radiation exposure and 1, 4, and 8 months after they began the radiation therapy. The patients received 60 Gy in tumoral area fractionated over 6 weeks. The contralateral normal brain hemisphere received a radiation dose from 20 to 50 Gy. The main metabolite concentrations (N-acetylaspartate (NAA), choline compounds (Cho), creatine (Cr), and lactate (Lac) were evaluated by the areas of the peaks after peak fitting. Normalized values (NV) were obtained by processing the ratio of the peak area of a given metabolite to the sum of all the spectrum peak areas; ratios (NAA/Cho, NAA/Cr, and Cho/Cr) were processed. One patient, who received panencephalic radiotherapy (30 Gy) after metastasectomy from a primary kidney adenocarcinoma, has been monitored with 1H-MRS eight times for 6 months to observe the onset of the metabolic changes. RESULTS: Changes were observed in irradiated normal brain tissue 4 months after radiation therapy began: the NAA/Cho and NAA/Cr ratios and the NAA (NV) decreased while the Choline (NV) increased. Four months later, normal values were recovered. CONCLUSION: 1H-MRS has the potentiality to detect and to evaluate in vivo early adverse metabolic effects of radiation therapy in the normal human brain. These changes are significant 4 months after the radiation therapy began and appear to resolve over time.

Impact of targeting deviations on outcome in medulloblastoma: study of the French Society of Pediatric Oncology (SFOP).

PURPOSE: To correlate targeting deviation in external beam radiation therapy with site of relapse in a prospective study of 174 patients treated for medulloblastoma. METHODS AND MATERIALS: Between February 1992 and February 1998 the radiotherapy treatment records were reviewed by a panel of radiation oncologists for 174 children treated with radiation therapy for medulloblastoma. The review was done without knowledge of patient outcome. Patterns of relapse were correlated with the results of the quality control review. RESULTS: Among the 174 patients five relapsed before the start of radiotherapy. One hundred sixty-nine patients were evaluable for correlation between targeting deviation and site of relapse. Number of major deviations in radiation therapy treatment is strongly correlated with the risk of tumor relapse (67% [95% CI: 28-91] of 3-year relapse rate in patient group with 2 major deviations and 78% [95% CI: 35-96] with 3 major deviations). This is particularly correlated with relapse in the frontal region of the brain: 5 relapses occurred in the frontal region in patients with major deviation in this area. An erroneous choice of electron beam energy is also linked with craniospinal fluid (CSF) relapse (3-year relapse rate of 68% [95% CI: 42-86]). Minor deviations in therapy technique are slightly associated with an increased risk of relapse in the same range as the group with only one major deviation. CONCLUSION: The quality of medulloblastoma radiation therapy technique is strongly correlated with outcome. Pretreatment central quality assurance review or standardized computer-designed blocks would improve survival to an extent equivalent to that attributed to adjuvant chemotherapy.

Quality control of radiotherapeutic treatment of medulloblastoma in a multicentric study: the contribution of radiotherapy technique to tumour relapse. The French Medulloblastoma Group.

Between 06.86 and 11.89, 88 medulloblastoma or primitive neuroectodermic tumour (PNET) localised in the posterior fossa have been included in the M7 multicentric protocol, 82 received the totality of the radiotherapy treatment and were evaluable for this study. Twenty-two of these 82 patients relapsed: their radiotherapy treatment is analysed in the present study. In 10 cases out of the 22 relapses treatment failure was probably due to a radiotherapeutic imperfection. This study confirms the necessity of a strict radiotherapy control, particularly in multicentric study.

Combination of 5-FU cisplatinum and hypofractionated irradiation followed by split-course radiotherapy in 47 patients with unresectable non small cell lung cancer.

Forty-seven patients with unresectable non small cell lung carcinoma, 15 stage IIIA, 31 stage IIIB, 1 stage IV (cervical lymphadenopathy) were treated with a combination of three courses of chemotherapy and hypofractionated irradiation followed after 3 weeks by split course radiotherapy. Each course was repeated every 3 weeks with the following sequence: Cisplatinum (CDDP) (20 mg/m2) was given in a 20-min infusion, followed by a 2-h infusion of 5-fluorouracil (5-FU) (400 mg/m2) on days 1, 2, 5 and 6. Radiation with a dose of 3 Gy on the target volume was given on days 3 and 4--in one fraction for the former 27 patients, in 2 fractions of 1.5 Gy for the latter 20 patients with a 6-h interval--after a 2-h infusion of 5-FU (400 mg/m2). The results remain disappointing: the objective response rate was 53%, the median survival was 10 months for the series, and the one-year survival 47%. The median survival was 14 months for IIIA, 10 months for IIIB and IV. Regarding the therapeutic regimen there seems to be less morbidity with 2 fractions per day for which the median survival is nearly the same at 10 months (1 fraction/day) versus 12 months (2 fractions/day).

Sequential combination of 5-fluorouracil, cis-platinum and irradiation in unresectable non-small cell lung cancer.

Twenty patients with unresectable non-small cell lung carcinoma, 15 stage III and 5 stage IV (supraclavicular lymphadenopathy) were treated with a combination of three courses of chemotherapy and hypofractionated irradiation followed after 3 weeks by split-course radiotherapy. Each course was repeated every 3 weeks with the following sequence. Cis-platin (CDDP) (20 mg/m2) was given in a 20-min infusion, followed by a 2-h infusion of 5-fluorouracil (5-FU) (400 mg/m2) on days 1, 2, 5 and 6. Radiation with a dose of 3 Gy on the target volume was given on days 3 and 4, after a 2-h infusion of 5-FU (400 mg/m2). Split course of irradiation consisted of 16 Gy in 5 fractions repeated after 3 weeks interval. The objective response rate was 75%. Median follow-up was 24 months, the median survival was 14 months. The 1-year survival was 53% and the 2-year survival was 16%.

[Combination of induction chemotherapy with surgery and/or radiotherapy in locally advanced head and neck cancers. A retrospective analysis of a series of 125 patients]. / Association chimiothérapie d'induction, chirurgie et/ou radiothérapie, dans les cancers localement avancés de la tête et du cou. Analyse rétrospective d'une série de 125 patients.

The prognosis of locally advanced cancers of the head and the neck is pejorative, particularly when nodal involvement is present. In order to improve local control and to reduce distant failures, we have treated stages III and IV patients with induction chemotherapy. From May 1986 to November 1992, 125 patients with squamous cell carcinoma of the head and neck were treated by induction chemotherapy: cisplatine (100 mg/m2 at J1) and 5FU (1 g/m2 from J1 to J5 in continuous infusion) every 21 days subsequent local therapy consisted of surgery for patients with resectable disease, and/or radiotherapy. One hundred and nineteen patients were assessable (110 men and 9 women) with a median age of 57 years (range: 36-78). All patients had performance status inferior or equal to 2. According to the TNM of UICC classification 50 patients were stage IV (42%), 61 stage III (51%), 7 stage II (6%) and a stage I (1%). One hundred (84%) patients have received at least 3 cycles of chemotherapy. Seventy-four patients (62%, IC: 60.4-63.5) had clinical objective response (complete response (CR) or partial response (PR)) with 24 patients (20%) CR and 50 patients (42%) PR. Local therapy included surgery in 81 patients (68%) and radiotherapy alone in 42 patients (35%). Overall, 103 patients (87%) were rendered clinically disease-free by treatment on this protocol. The toxicities of cisplatine and 5-FU chemotherapy consisted predominantly of myelosuppression (5%) and renal toxicities (4%) and were moderate as described for this combination. At a median follow-up of 32 months, the median survival is 38 months (CI 95%, 18-54 months), and the median time to progression is 62 months. The oropharynx localization reached statistical significance for survival rates (Log-rank test, p = 0.02).

[Evaluation of a series of 137 carcinomas of the endometrium of stage I TNM/UICC]. / Evaluation d'une série de 137 carcinomes de l'endomètre de stade I TNM/UICC.

PURPOSE: To assess retrospectively the long-term results of the combination of surgery and radiotherapy in carcinoma classified cT1. PATIENTS AND METHODS: From 1974 to 1993, 137 women suffering from endometrial carcinoma cT1Nx-0 M0 were entered into the study. The median age was 62 years (range: 39-85 years) and the median follow up was 67 months (range: 0-224 months). RESULTS: Surgery was performal in 132 women (96.35%). For cT1, the 5-year overall and specific survivals were 81.1% and 84.5%, respectively. The 10-year overall and specific survivals were 68.8% and 82.2%, respectively. Concerning cT1pT1, the 5-year overall and specific survivals, were 83.9% and 87.4%. The 10-year overall and specific survivals were 71.1% and 85%, respectively. Histological grade, pelvic lymph node involvement and myometrial infiltration influence significantly the overall and specific survivals of cT1pT1 tumors. According to multivariate analysis, pelvic lymph node involvement was a powerful prognostic factor for both the overall and specific survivals. If we rule out pelvic lymph node involvement, WHO histological grade was a significant prognostic factor. CONCLUSION: Combination of surgery and radiotherapy is still a common procedure for cT1 tumors. When surgery is done before radiotherapy, tailored irradiation may further take place, according to WHO histological grade and pelvic lymph node status.

[Lymphopenia and variations in T and B lymphocytes appearing immediately after irradiation (author's transl)]. / Lymphopénie et variation des lymphocytes T et B dans les suites immédiates de l'irradiation.

Immunity tests were conducted in 21 patients with cancer, before and two months after irradiation. T and B lymphocyte counts were normal before irradiation when compared to a control group. Lymphopenia was present after irradiation affecting mainly the T lymphocytes (P = 0.005), whereas changes in B lymphocytes were not significant. These results suggest that irradiation has an immunosuppressive effect which should be studied in greater detail to establish possible therapeutic applications.

[Absorbed dose during helical acquisition CT. Effect of acquisition parameters]. / Dose délivrée lors d'un examen scanner en acquisition hélicoïdale. Influence des paramètres d'acquisition.

PURPOSE: European directive 97/43 specifies that the dose delivered to the patient during a radiological procedure should be estimated. In order to prepare for implementation of this new regulation, we have studied the dose delivered during spiral CT acquisition. MATERIALS AND METHODS: We have studied the influence of slice thickness, pitch, tube voltage and intensity, and acquisition volume length. We present measurements for single and dual detector CT scanners. We used a pencil ionization chamber to measure air kerma. We measured absorbed dose in water with a waterproof ionization chamber set in a semi-customized phantom filled with water. Chambers were set on the rotation axis of the CT scanners. We studied the dose outside the acquisition volume. RESULTS: We quantified the influence of each parameter on the absorbed dose. We used our measurements to calculate the dose for different acquisition protocols. Also we evaluated the dose to organs distant from the acquisition area. CONCLUSION: This study is one step toward a systematic estimation of the dose delivered to patient during helical CT exams. To use these results in daily practice, we have to develop software using our measurements.

[Role of the practitioner after accidents related to ionizing radiation]. / Rôle du médecin après un accident lié aux rayonnements ionisants.

Accidents due to ionizing radiations can be nuclear accidents, concerning a large part of the population, or radiological accidents which may, at higher doses, irradiate a limited number of persons. In case of nuclear accident, radioactive rejections lead to an irradiation and/or a contamination, and induce the "préfet" to take public health measures. According to the dose possibly received by the population, measures can be the continuation of normal life, confinement, distribution of stable iodine, restriction of certain food consummation, evacuation being the ultimate measure. General practitioner will be an important actor in the information of the populations. When a radiological accident occurs, the management will depend on the type of accident and the dose emitted. This treatment of medico-surgical emergency is an absolute priority, if traumatic lesions are associated, on nuclear risk, especially when prognosis for life is involved. Lesions associated to radiolesions worsen the prognosis.

[Analysis of loco-regional control rate, metastatic remission and survival in 178 breast cancer patients treated by radical modified mastectomy and post-operative irradiation (author's transl)]. / L'irradiation post-opératoire dans les cancers du sein. Analyse du contrôle loco-régional, de la rémission métastatique et de la survie, à propos de 178 cas.

178 cases of post-operative irradiation for breast cancer (145 T1, T2, T3 and 33 T4) are analyzed. According to the surgical procedure there are 146 cases of radical modified mastectomy (Patey) and 32 cases of radical mastectomy (Halsted). The axillary status reveals 50% of involved nodes, but radiotherapy has been systematic on chest wall and supra-clavicular, parasternal, axillary lymph nodes areas. Loco-regional failures are only situated on chest wall (3,9%) and in the supraclavicular area (1,7%). The five year actuarial rate of locoregional control is 93% and 98% if we exclude 7 locoregional failures contemporaneous or consecutive to a metastatic evolution. The five year actuarial rate of metastatic remission for patients with negative axillary nodes (N-) is 83% against 55% for N+ (p < 0,001). The five year actuarial survival rate is 92% (N-) and 64% (N+) (p < 0,001). We discuss about indications of selective irradiation of chest wall and parasternal area for patients with negative axillary nodes and also about post-operative immuno-suppression, and chronology of chemotherapy.

[Conservative treatment of breast carcinoma with or without prophylactic chemotherapy. Preliminary results in 45 cases (author's transl)]. / Traitement conservateur du cancer du sein avec ou sans chimioprophylaxie. Résultats préliminaires à propos de quarante-cinq observations.

Between February 1969 and December 1979, 45 breast carcinomas T1 NO or T2 NO (greater than 3cm) were treated by tumorectomy and radiotherapy. Axillary dissection was performed in 22 cases. Twenty-one pre-menopausal patients were castrated either by oophrectomy (13 cas) or by pelvic irradiation (8 cases). From 1977 on, (10 cases) prophylactic chemotherapy using cyclophosphamide, 5 FU, methotrexate, vincristine, was administered for 4 to 6 months according to the number of poor prognostic factors. The five-year actuarial remission rate was 93% (84-100), the metastatic remission rate was 88% (72-100). Indications of prophylactic chemotherapy in forms with good prognostic factors are discussed.

[Survey of the use of contention shells in Centre-Rhône-Alpes area]. / Enquête sur l'utilisation des moules de contention dans la région Centre-Rhône-Alpes.

Contention shells are frequently used in radiotherapy. They allow improvements in the reproducibility of treatments and take part in quality assurance. The aim of our survey is to establish how centers use contention masks. Ninety-five percent of the centers questioned use contention masks. The fixation device is in most cases made of Plexiglas. The masks are always made of thermoplastics materials with low modeling temperature. They are made just before simulation or scanner by a radiographer. The surface dose problem can be overcome by two different techniques. One consists in the stretching of the material to reduce the density. The other consists of cutting out the mask where the irradiation fields are projected. Whatever the technique, there is a loss of rigidity of the mask, which means the immobilization is not so effective. Despite drawbacks, contention masks have an important role in the quality insurance in radiotherapy.

[Association of 5-FU, CDDP and hypofractionated radiotherapy in recurrences of subtentorial astrocytomas and malignant gliomas in adults]. / L'association 5-FU/CDDP/radiothérapie hypofractionnée dans les récidives des astrocytomes et des gliomes malins sustentoriels de l'adulte.

Twenty-seven patients who had a relapse of astrocytomas or supra-tentorial malignant gliomas, previously treated by radio-surgical combination or exclusive irradiation, underwent a combination of 3 courses of 5-FU, cis-platyl and hypofractionated irradiation. No objective response was observed, but there was a progression of the tumor in 33% of the cases, and no change in 67%. Overall median survival was 7 +/- 1.5 months. The 20 patients with grade III or IV astrocytomas had a lower median rate than the 7 patients with grade II astrocytomas or oligodendrogliomas: 6 +/- 1.8 months versus 18 +/- 3.2 (P = 0.16). Median survival was 14 +/- 2.7 months for neurological responders and 6 +/- 2.1 months for non-responders (P = 0.017).

[Non-gonadic complications of chemoradiotherapy in Hodgkin's disease. A study of eighty-three patients (author's transl)]. / Complications non gonadiques de l'association chimio-radiothérapie dans la maladie de Hodgkin. A propos d'une série de quatre-vingt-trois observations.

Eighty-three patients with Hodgkin's disease were treated with a combination of chemotherapy and radiotherapy. 43 were included in protocol 1 (from january 1970 to january 1974) and 40 in protocol 2 (february 1974 to december 1977). In protocol 1, staging laparotomy was not systematically performed (20 cases). Treatment consisted of 2 intravenous injections in Vinblastine and total nodal irradiation. In protocol 2, laparotomy was systematic in patients over 50 (35 cases). Patients with stages 1 and II treated as mentioned above. Patients with stage III received two Mopp courses followed by total nodal irradiation. Patients older than 50 with stages I and II and poor prognosis factors received chemotherapy only. Laparotomy was associated with a 0% mortality rate and a 3,6% morbidity rate. No myelitis or pericarditis were observed. Herpes zoster occurred in 24% of the patients, pulmonary apex fibrosis in 6%, hypothyroiditis in 2,4%, and leucopenia in 3,6%. Two late infectious complications were fatal. No solid tumor was apparent. Acute leukemia and non-Hodgkin malignant lymphoma developed in two patients. Good tolerance, shortness of treatment, and remission rate, warrant the pursuit of protocol 2 in which systematic laparotomy for patients under 50 allows total nodal irradiation and therefore reduction of chemotherapy.