Intraoperative radiation therapy combined with limited lymph node resection in gastric cancer: an alternative to extended dissection?

PURPOSE: To describe the results of a series of 63 Western patients presenting with gastric adenocarcinoma and treated with surgery and intraoperative radiation therapy (IORT) over a 8-year period and to discuss the role of IORT when combined with limited lymph node dissection. METHODS AND MATERIALS: From 1986 to 1993, 63 patients with gastric adenocarcinoma have been operated in the department of radiation oncology of the Hospices Civils de Lyon. The stage was: I in 17, II in 11, IIIA in 9, IIIB in 20, and IV in 6. The lymph node dissection was considered to be limited in 56 patients and extended in 7. The IORT dose ranged from 12 to 23 Gy (median: 15). Thirty patients also underwent a postoperative external beam irradiation with a standard dose of 44-46 Gy. RESULTS: The postoperative mortality rate was 4.8%. The 5-year overall survival in the entire series was 47% and was 82, 55, 78, 20, and 0% in Stages I, II, IIIA, IIIB, and IV, respectively. Loco-regional relapse occurred in 15 of 63 patients and metastases in 15 of 63. CONCLUSION: In Western patients treated by gastrectomy for adenocarcinoma of the stomach, IORT combined with limited lymph node dissection may provide overall survival similar to that observed after gastrectomy with extended lymph node dissection but with less postoperative mortality.

Stereotactic radiosurgery for arteriovenous malformations of the brain using a standard linear accelerator: the Lyon experience.

Radiosurgery (RS) was initiated in Lyon in October 1989. The technique was adapted from that described by Lutz and Saunders in Boston (BRW stereotactic frame). Irradiation is delivered with 18-MV photons produced by a LINAC. From December 1989 to December 1992, 41 patients with arteriovenous malformations were treated by RS; the median age was 33 years. The largest lesion diameter was 11.2-38.5 mm. Fifteen to 20 Gy were delivered on the 70% isodose line. Angiography was performed at 2 years post-treatment in 32 patients demonstrating an overall complete thrombosis rate of 81.3%. This incidence was significantly correlated with the Spetzler and Martin grade before RS (P = 0.0055). Two patients (4.9%) experienced haemorrhage after radiosurgical treatment and one died from an intracerebral-intraventricular haemorrhage. Four patients (9.7%) experienced permanent radiation-induced neurological complications.

Endocavitary irradiation for early rectal carcinomas T1 (T2). A series of 101 patients treated with the Papillon's technique.

PURPOSE: This work is a retrospective analysis of a series of patients treated with endocavitary irradiation stressing the role of transrectal ultrasound (TRUS), which has been used routinely in the staging since 1987. METHODS AND MATERIALS: Between 1977 and 1993, 101 patients with infiltrating adenocarcinomas were treated. Clinical staging was 65 T1 N0 and 36 T2 N0. TRUS used in 36 patients showed: 22 UT1 N0, 10 UT2 N0, and 3 UT2 N1. Contact x-ray was delivered with a 50 kV radiotherapy unit. The median dose was 92 Gy (60-125) in five fractions, 55 days. In 28 patients a boost was given with 192Ir implant delivering a median dose of 25 Gy/21 h. RESULTS: Complete response was observed in all patients at the completion of treatment. Loco-regional failures were seen in 14 patients (local in 7 patients, nodal pararectal in 6 patients, and local + nodal in 1 patient). A curative salvage treatment was attempted in 13 patients and resulted in an ultimate pelvic control rate of 99 patients. Rectal preservation was possible in 92 patients. Overall and specific 5-year survival was 83.3% and 94.4%. No serious complication was observed. TRUS was more sensitive than digital rectal examination to detect involvement of pararectal metastatic nodes (N1). No loco- regional relapse was observed out of 22 UT1 N0. CONCLUSION: Endocavitary irradiation can cure early adenocarcinoma of the rectum without complication. TRUS appears as a significant improvement in the selection of patients amenable to this treatment. If restricted to UT1 N0 tumors, endocavitary irradiation should control locally more than 90% of these patients. Any UN1 is a contraindication for endocavitary irradiation alone.

Prevention of radiation related complications in the treatment of rectal adenocarcinoma. The importance of the dose volume relationship.

AIM: To illustrate and stress the role of the dose volume relationship in the risk of radiation induced rectal complications. METHODS: With different techniques of irradiation like contact x ray therapy, Iridium implant, external beam irradiation, intra operative electrontherapy, it is possible to irradiate different volumes from few centicubes to liters. RESULTS: The data from the literature clearly demonstrate that high doses can be given safely in small volumes, but that doses of 50 Gy or more in large volumes are dangerous. The irradiation of the whole pelvis through two antero posterior (AP - PA) fields ecompassing more than 4 liters should not be recommended. Other classical risk factors must be taken into account when planning the treatment. Previous surgery, obesity, diabetus, collagen disease, combined chemotherapy, all these factors can lead to a modification of the irradiation technique. CONCLUSIONS: A perfect technique of irradiation is mandatory to achieve the best therapeutic ratio when treating rectal cancer. To avoid severe complications the dose must be closely adapted to the irradiated volume.

[Current treatment of cancers of the anal canal]. / Le traitement actuel des cancers du canal anal.

The major development in the treatment of cancers of the anal canal, over recent years, is the now predominant role of radiotherapy which has replaced amputation surgery as first-line treatment. All stages combined, the average 5-year global survival rate is now 60%, with a local control rate of 70% and good sphincter preservation in the majority of healed patients. However, many questions remain unresolved in these rare cancers: what is the optimal irradiation technique, what is the role of chemotherapy in this very chemosensitive tumour but associated with a low risk of metastases? Amputation surgery still plays an important role, but the exact time at which it should be proposed remains controversial. The rate of inguinal lymph node invasion is approximately 20%. The value of systematic treatment N0 inguinal nodes remains controversial. As for most problems of clinical oncology, only randomized trials rapidly conducted on a large scale will be able to provide an answer to all these questions.

Stereotactic radiosurgery: the Lyon experience.

From 10/1989 to 12/1992, 135 patients were treated, in Lyon, by Stereotactic Radiosurgery (RS) +/- External beam Radiotherapy (EBRT). Indications were AVMs or tumours that could not be cured by embolisation or/and surgery and are not larger than 30 to 35 mm. Lesions received 15 to 20 Gy (70% isodose) in one course. Among the 42 AVMs, only one rebled 6 months after RS and 9/15 had clinical improvement. Thirty-one had a radiological follow-up of 4 to 29 months after RS. Ten were totally obliterated, seven regressed more than 80% and six had a reduction of 50 to 80% of their AVM. Three grade 3 radio necrosis occurred for a cerebral trunk AVM and two large lesions. Three of the 15 treated meningiomas progressed after RS, 2 of them were controlled by conventional surgery. Four out of nine presenting symptoms had clinical improvement and, with a radiological follow-up of 4 to 24 months, 5 were stabilised and 6 regressed. Two grade three complications occurred for large lesions. The biological and radiological results of RS were good for the 42 treated pituitary adenomas but the high visual complication rate (12/42 with 8 grade 3) was too important and we stopped RS for these tumours except for small (less than 2 cm) adenoma at some distance from the optic chiasma. The visual complications were related to the tumour volume, the distance between the adenoma and the visual tract and pre-existent visual alterations.(ABSTRACT TRUNCATED AT 250 WORDS)

Curative endocavitary irradiation of small rectal cancers and preoperative radiotherapy in T2 T3 (T4) rectal cancer. A brief overview of the Lyon experience.

The aim of this study was the analysis of 414 patients treated by endocavitary irradiation for small T1 (T2) infiltrating adenocarcinomas between 1951-93 and of 337 patients treated by preoperative radiotherapy for T2 T3 (T4) rectal cancer, between 1978-92. Endocavitary irradiation was delivered with Papillon's technique using the PHILLIPS RT-50 machine. Preoperative external beam radiotherapy was given to the posterior pelvis only with an accelerated schedule of 39 Gy in 13 fractions over 18 days. Endocavitary irradiation with the use of intra-rectal ultrasound for patient selection resulted in a local control rate of 91% with no complication even in the medically inoperable patients. Preoperative external beam radiotherapy followed by radical resection resulted in a 90% pelvic control rate. Sphincter-sparing surgery was possible in 60% of patients with low or middle rectal lesions.

Radiation therapy in the conservative treatment of carcinoma of the anal canal.

PURPOSE: Radiotherapy is the standard treatment of anal canal carcinoma. We retrospectively analyzed our experience with 108 patients. Special attention was given in evaluating 51 patients who received concomitant chemotherapy with 5-FU-CDDP. METHODS AND MATERIALS: From January 1980 to December 1989, 108 patients with anal canal carcinoma were treated with exclusive radiotherapy at the Centre Hospitalier Lyon Sud. There were 11 men and 97 women, mean age was 65 years (30-86). Histologic types were 94 epidermoid carcinomas, 13 basaloid carcinomas, and one adenocarcinoma. The TNM classification (UICC 87) was: 16 T1 (14.8%), 53 T2 (49%), 33 T3 (39.5%), six T4 (5.5%), 77 N0 (71.3%), 20 N1 (18.5%), nine N2 (8.3%) and two N3 (1.8%). Papillon's radiotherapy technique with a Cobalt direct perineal field was used in 82 patients. Ninety-six patients were treated with an interstitial 192Ir implant with a mean delay of 55 days after the end of the radiotherapy. In 59 patients at least one course of either 5-FU-mitomycin (8) or 5-FU-CDDP was added with at least one course concomitantly to the radiotherapy in 53 patients. RESULTS: A complete response in 104/108 patients (96%) was obtained 2 months after the brachytherapy. A locoregional relapse (local and/or pelvic failure) was seen in 18 patients (16.6%) and inguinal node relapse in nine (8.3%). Eight patients with locoregional recurrence and five with inguinal relapse were salvaged. A systemic failure occurred in six (5.5%) patients. Twenty-nine patients died, 16 of progressive disease. One patient died of treatment related toxicity. The overall 5-year survival was 64% +/- 6 and specific survival 72% +/- 8. None of the patient parameters was found to be statistically significant but there was a trend toward longer 5-year survival in T1-T2 patients and in those with well or moderately differentiated tumors. Noteworthy are the same survival rates for N0 and N1-N3 patients (65 vs. 62%). The objective response and the locoregional failure rates were similar in the patients treated with or without chemotherapy. The difference did not reach statistical significance though it was important for the following parameters: overall survival rates for T1-T2 with and without chemotherapy (94 vs. 61%) and for N1-3 patients (73% vs. 27%). The main prognostic factors in this series were differentiation (5-year overall survival with chemotherapy 95% vs. 27% without chemotherapy p = 0.02) and the response at 3 months after treatment initiation, before brachytherapy implant (5-year overall survival for complete responders and "very good responders" 71% vs. 34% in partial responders p = 0.002). The complications rate was acceptable (Grade III 9%, Grade II 14%). Anal preservation was possible in 85% of the patients (92/108). Nine abdominoperineal resection were performed for recurrence and seven for severe necrosis. The T3-T4 group abdomino perineal resection was 23% while it was 9.2% of the T1-T2 group. CONCLUSION: We confirm that exclusive radiotherapy is the treatment of choice for epidermoid carcinomas of the anal canal. The role of chemotherapy is still unclear.

[Role of peroperative radiotherapy in the treatment of uterine cancers. Preliminary experience in Lyon]. / Place de la radiothérapie peropératoire dans le traitement des cancers de l'utérus. Expérience lyonnaise préliminaire.

AIM: Retrospective analysis of Intra operative Radiotherapy (IORT) in recurrent uterine carcinoma (RUC) and prospective pilot study of IORT in advanced cervix cancer (ACC) with high risk of local failure. PATIENTS-TREATMENTS: 1) RUC: from 1988 to 1991, 34 patients with RUC have been treated. Primary cancer was: cervix uterus: 28, endometrium: six. Site of recurrence: centro pelvis: four, latero pelvis: 25, lombo aortic: five. Total gross resection was only possible in 12 patients. A dose of 15 to 22 Gy was given by IORT according to the residual tumour size. External beam irradiation was added in 16 patients; 2) ACC: January 1991 to November 1992, 20 patients were included in this pilot study, stage IIB: seven, stage III: 12, stage IV: 1. Preoperative retroperitoneal pelviscopy showed 13 pN1 patients and NMR imaging ten tumours of 6 cm or larger in diameter. Treatment started with concommitant pelvic irradiation (44 Gy) and one conommitant cycle of 5 Fu-CDDP, followed by a short course of high dose rate upper vagina brachytherapy (4 Gy). Four weeks later a radical Wertheim operation was performed together with IORT on the lateral pelvis. RESULTS: 1) RUC: overall survival (Kaplan Meier) at 4 years is 32% (+/- 8). Local relapse in the fiedl of IORT was observed in six patients. Grade 2-3 complications: six patients (radiation proctitis, neuritis, vertebral collapse, ureteral stenosis); 2) ACC: the median follow up is hort (18 months). Four cases of pelvic relapse, no postoperative death. The first line radio chemotherapy was associated with two G3 early complications. Postoperative radiation complication was less than 10% G3. DISCUSSION: promising results of IORT in RUC have been observed especially if no irradiation is given during the primary treatment. Good feasibility of the pilot study of IORT in ACC was also observed. It could be followed by a multicentric feasibility trial.

[Radiotherapy in cancer of the rectum]. / La radiothérapie dans le cancer du rectum.

The response of adenocarcinoma of rectum to radiotherapy is dependent on the use of irradiation techniques that ensure a sufficient dose be applied to the tumor without exceeding tolerance limits of pelvic tissues. This has been clearly demonstrated by results of contact radiotherapy over the last 30 years or so. Doses of about 100 Gy provide local control in 90% of cases and a 5 year survival rate of 80% in patients with highly selected tumors. For several years now, contact radiotherapy has been associated with external irradiation and iridium therapy with resulting sterilization of T2 and even T3 or N1 tumors in inoperable cases. Endorectal ultrasound imaging is essential for selecting those patients requiring radiotherapy alone and for evaluating the results, but in more than 90% of patients, surgery remains basic treatment for cancer of rectum. The incidence of local recurrence, very difficult to treat, is non negligible, however, but combining radiotherapy with surgery has been shown to reduce the rate of by 50%. Opinions differ on the relative efficacy of pre- or post-operative radiotherapy, but tolerance to this treatment is good in both cases if the technique used limits radiation to the posterior pelvis. Results of a Swedish randomized trial demonstrated greater efficacy for pre-operative radiotherapy for controlling local spread. Meta analysis showed that irradiation produces a definite gain in local control with a resulting gain in survival of about 5 to 10%. In the USA, chemotherapy based on 5 FU combined with post-operative radiotherapy was equally favorable in terms of survival. Pre-operative radiotherapy may also increase the chance of conservation of the sphincter. Although numerous points concerning chronology and mode of treatment remain open to discussion, a combination of radiotherapy and surgery now appears as standard treatment for rectal cancer.

[Stereotactic radiosurgery. Preliminary experience of a team of Lyon]. / La radiothérapie stéréotaxique multifaisceaux. Expérience préliminaire d'une équipe lyonnaise.

Radiosurgery (RS) is a new technique that is being developed worldwide to treat a variety of central nervous system (CNS) diseases. We report preliminary results concerning the first 35 patients treated at our institution between October 1989 and December 1990. These patients presented with pituitary adenomas (PA: 12 patients), primary CNS tumors with different histologies (11 patients), arteriovenous malformations (AVM: 6 patients), acoustic neurinomas (3 patients) and CNS metastases (3 patients). All patients were treated with a linear accelerator and received a single dose of 20 Gy delivered on the 70% isodose curve localized stereotactically by mean of either a CT scan or angiography. Preliminary results with a median follow-up of 26 months were as follows. AVM had totally disappeared in 3 patients after 12 and 17 months, and remained stable in 3 at 6 and 26 months. In 3 PA patients, the adenoma was partially regressed on the CT scan and, in 2 patients, the visual field was moderately improved; none experienced clinical improvement due to hormonal hypersecretion. One patient with neurinoma experienced clinical improvement, but the CT scan remained unchanged in the 3 patients. Of the patients with primary or secondary tumors, 8 exhibited a reduced lesion diameter on the CT scan, but 3 died later of progressive disease. Complications were not rare. In 7 patients, delayed reactions were observed: one case of cerebral edema reversed under corticotherapy; and 6 cases of neurological impairment due to brain necrosis, reversed in only one. RS appears to be an interesting approach for the treatment of deeply located AVM and for small acoustic neurinomas.(ABSTRACT TRUNCATED AT 250 WORDS)

[Sexual activity after pelvic irradiation for cancer of the prostate. Evaluation by questionnaire]. / Activité sexuelle après irradiation pelvienne pour cancer de la prostate. Evaluation par questionnaire.

In order to determine the influence of pelvic radiotherapy on potency, a questionnaire has been sent to all living patients who had been treated for a prostate carcinoma with exclusive external beam radiotherapy from 1980 to 1991 in Centre Hospitalier Lyon Sud. One hundred and six patients have been asked about the frequency of intercourse prior to and after treatment, and about possible modifications of their sexual activity after radiotherapy. At the time of the study, median follow-up was of 47 months. 5 and 10 years survival rates were respectively 76 and 53% for overall survival, and 65 and 33% for disease-free survival. Severe complications rate related to radiotherapy was 2%. Among the 56 patients who returned a completed questionnaire, 12 (21%) were impotent prior to treatment. During the first year after radiotherapy, 10 patients were given an hormonal treatment and became impotent. Among the other 34 evaluable patients, 20 (59%) patients were still potent one year after radiotherapy, and sexual activity was unchanged for 3 patients (15%), slightly altered for 11 patients (55%) and altered for 6 patients (20%). Erection capacity was modified for 82% of the patients, ejaculation for 59%, orgasm for 47% and libido for 6%. In order to determine prognostic factors of conservation of sexual activity, we analyzed the distribution of potent and impotent patients according to age, tumor stage, Gleason score, frequency of intercourse prior to treatment and size of the radiation fields. Only age < or = 64 was associated with a higher percentage of preservation of potency: 76% versus 59% in patients older than 64 (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)