Limiting factors for development of ambulatory breast surgery in the French hospital network.

INTRODUCTION: Ambulatory breast surgery is not well developed in France. This is especially true for oncologic procedures, MATERIALS AND METHODS: Between January 2005 and June 2006, we performed a retrospective evaluation of the factors thought to limit the development of this type of hospitalization. RESULTS: The principal limiting factors were distance restrictions (respect of the 100 km perimeter), the complexity of patient management for small breast tumors (several practitioners involved) and last, the non-motivating reimbursement policy. CONCLUSION: By changing to the Anglo-American ("one day surgery", i.e. hospital stay less than 24 hours) or hybrid system (less than 12 hours+1 day surgery), ambulatory surgery could easily be offered to patients excluded by the current system (ambulatory department open less than 12 hours).

[Perioperative interstitial brachytherapy for recurrent keloid scars]. / La curiethérapie interstitielle périoperatoire dans le traitement des cicatrices chéloïdes récidivantes.

PURPOSE: Evaluation of the results of perioperative interstitial brachytherapy with low dose-rate (LDR) Ir-192 in the treatment of keloid scars. PATIENTS AND METHODS: We performed a retrospective analysis of 73 histologically confirmed keloids (from 58 patients) resistant to medicosurgical treated by surgical excision plus early perioperative brachytherapy. All lesions were initially symptomatic. Local control was evaluated by clinical evaluation. Functional and cosmetic results were assessed in terms of patient responses to a self-administered questionnaire. RESULTS: Median age was 28 years (range 13-71 years). Scars were located as follows: 37% on the face, 32% on the trunk or abdomen, 16% on the neck, and 15% on the arms or legs. The mean delay before loading was four hours (range, 1-6h). The median dose was 20Gy (range, 15-40Gy). Sixty-four scars (from 53 patients) were evaluated. Local control was 86% (follow-up, 44.5 months; range, 14-150 months). All relapses occurred early - within 2 years posttreatment. At 20 months, survival without recurrence was significantly lower when treated lengths were more than 6cm long. The rate was 100% for treated scars below 4.5cm in length, 95% (95% CI: 55-96) for those 4.5-6cm long, and 75% (95% CI: 56-88) beyond 6cm (p=0.038). Of the 35 scars (28 patients) whose results were reassessed, six remained symptomatic and the esthetic results were considered to be good in 51% (18/35) and average in 37% (13/35) (median follow-up, 70 months; range, 16-181 months). CONCLUSION: Early perioperative LDR brachytherapy delivering 20Gy at 5mm reduced the rate of recurrent keloids resistant to other treatments and gave good functional results.

[Maxillary sinus cancers: Prognosis and quality of life: a retrospective study of 22 cases]. / Cancers du sinus maxillaire: pronostic et qualité de vie.

OBJECTIVES: Maxillary sinus cancer is uncommon. We present a study of 22 cases of patients managed at the Nantes University Hospital for maxillary sinus cancer during the time period 1989-2002. MATERIALS AND METHODS: Clinical and oncological characteristics of the tumors were evaluated. Treatment and results were evaluated in association with the patients' quality of life, estimated with a questionnaire survey sent to surviving patients. RESULTS: Carcinomas predominated (68%). The TNM classification was: T2: 45.5%, T3: 45.5% and T4: 9%. 89% of necks were N0 and 9% were N1. Treatment course (determined after imaging) was surgical removal of the tumor by total maxillectomy: 77.5%; partial maxillectomy: 22.5%, associated with post-operative radiotherapy. Esthetic consequences and disabilities of patients assessed by the questionnaire pointed out that 68% of them were complaining of poor quality of life. Global survival at 12 months was 63%, 20% at 24 months and 9% at 5 years. There were no statistically significant differences between specific survivals according to T-stage nor according to histological features. The difference was significant when surgical removal of the tumour was large according to post-operative histology. CONCLUSION: Authors conclude that maxillary sinus cancers exhibit poor prognosis, and focus on the necessity of quality of life assessment.

[Interstitial brachytherapy of peri-orificial skin carcinomas on the face]. / Curiethérapie interstitielle des cancers cutanés des zones périorificielles de la face.

Purpose. - To analyse outcomes after interstitial brachytherapy of facial periorificial skin carcinomas. Patients and methods. - We performed a retrospective analysis of 97 skin carcinomas (88 basal cell carcinomas (BCCs), 9 squamous cell carcinomas (SCCs)) of the nose, periorbital areas and ears from 40 previously untreated patients (group 1) and 57 patients who had undergone surgery (group 2). The average dose was 55 Gy [50-65] in group 1 and 52 Gy [50-60] in group 2 (mean implantation times: 79 and 74 hours respectively). We calculated survival rates and assessed functional and cosmetic results de visu. Results. - Median age was 71 years [17-97]. There were 29 T1, 8 T2, 1 T3 and 2 Tx tumors in group 1. Tumors were<2 cm in group 2. Local control was 92.5% in group 1 and 88% in group 2 (median follow-up: 55 months [6-132]). Five-year disease-free survival was better in group 1 (91% [75-97]) than in group 2 (80% [62-90]), P=0.23. Of the 34 patients whose results were re-assessed, eight presented pruritus or epiphora. One group 2 patient had an impaired eyelid aperture. Cosmetic results were better in group 1 than in group 2, with respectively 72% (8/11) vs 52% (12/23) of good results and 28 (3/11) vs. 43% (10/23) of fair results. Conclusion. - Brachytherapy provided a high level of local control and good cosmetic results for facial periorificial skin carcinomas that pose problems of surgical reconstruction. Results were better for untreated tumors than for incompletely excised tumors or tumors recurring after surgery.

[A study based on national DRG data to evaluate work load and practice relating to cancer patients in not-for-profit hospitals]. / Un essai d'exploitation de la base PMSI nationale pour évaluer le volume et les modes de prise en charge du cancer en secteur hospitalier non lucratif.

BACKGROUND: In France there is no reliable information describing the organisation of hospital care for patients with cancer. The present study attempts to clarify this issue taking advantage of an information source that has up to now been unused, namely the national PMSI (Information System Medical program) data base. METHODS: A quantitative study has been carried out regarding cancer management in France using information filed with the PMSI which compiles data related to hospital admissions in all institutions with more than 100 beds and subject to a defined global budget. The "cancer" component of hospital activity was extracted using a specific algorithm which utilized the diagnostic and intervention codes included in the admission summaries. By using the unit of activity as defined by the ISA (Activity Synthetic Index) and the scale of relative cost according to the GHM (Homogeneous Group of patients) it was possible to analyse the information in terms of a balance sheet. RESULTS: The study provided information regarding the costs and methods of management, including therapeutic strategies, for each type of hospital establishment. It is shown that with one death out of six, cancer covers a quarter of all hospital stays, and one sixth of annual hospital expenses. This accounts for 16.2% of ISA ie approximately 29 billion francs (4.6 billion dollars) for the public and semipublic sectors. Surgery, which accounted for 32% of expenditures, appeared to be the most expensive intervention, ahead of chemotherapy (16.3%) and radiotherapy (9.1%). Each type of hospital organisation (university, cancer centre, district hospital) had their own relative figures. CONCLUSION: Through this study the current situation regarding cancer care in hospital has been documented. It has also demonstrated the value of the PMSI data base as a source of information for large scale quantitative studies of health care economics. However, the PMSI does not yet provide details regarding infrastructure or succession of hospital stay. Ultimately, this analysis does not provide any information on the quality or efficacy of care but does define a typological system for health care organisations which could provide information on distribution of resources.

Final results of a randomized trial comparing chemotherapy plus radiotherapy with chemotherapy plus surgery plus radiotherapy in locally advanced resectable hypopharyngeal carcinomas.

After neoadjuvant chemotherapy, a routine conservative approach followed by salvage surgery was evaluated in terms of local control and survival in cases of advanced potentially resectable hypopharyngeal carcinoma. Between 1985 and 1989, 92 patients with T3 or T4-NO,N3 operable squamous cell hypopharyngeal carcinomas received three courses of neoadjuvant chemotherapy every 2 weeks involving a combination of cisplatin, 100 mg/m2, on day 1 and fluorouracil, 1 g/m2, on days 2 to 5, followed by total laryngopharyngectomy plus postoperative radiotherapy in 47 patients (arm A) or radiotherapy alone in 45 patients (arm B). Randomization was always performed prior to chemotherapy. The response rates of tumor and node to chemotherapy were, respectively, 67% in arm A versus 79% in arm B (P > 0.05) and 54% in arm A versus 73% in arm B (P > 0.05). Grade III or IV toxicity was similar, affecting 15% of patients and 7% of cycles in arm A versus 16% of patients and 6% of cycles in arm B. After a mean follow-up of 92 months, survival was statistically better (P = 0.04) in arm A (5-year overall survival, 37%; median survival, 40 months) than in arm B (19% and 20 months) because of a better local control rate (63% versus 39%; P < 0.01). Better results were obtained for mutilant surgery in terms of local control and overall survival, regardless of response to neoadjuvant chemotherapy.

Clinical experience with leuprorelin acetate before radiotherapy for prostatic cancer.

A total of 40 patients with stages A2 to C prostatic cancer were treated with leuprorelin acetate depot once a month for 2 months before being treated by pelvic irradiation or radical prostatectomy. In the 32 patients who were evaluable, seven (22%) were classified as minor responders after leuprorelin treatment and 23 (72%) as major responders when assessed by rectal examination. Prostate-specific antigens also returned to normal concentrations (5 ng/ml) in 26/31 (84%) patients. Leuprorelin acetate depot suppressed plasma testosterone concentrations to castration values during treatment, but concentrations returned to normal 2 months after completion of treatment. Following radical treatment, there were three deaths--one postoperative and two due to recurrent disease--but there was no isolated local relapse. It is concluded that the protocol was locally well tolerated and was effective in the treatment of stages B2 and C prostatic cancer patients.

Management of regional lymph nodes in carcinoma of the penis.

In the management of carcinoma of the penis, standard treatment of the primary tumor is by radiotherapy for small lesions (Tis, T1, T2 located in the glans) and by amputation in other cases (T2 with invasion of the shaft). The diagnosis and treatment of regional lymph nodes are thus the essential problems with this cancer. In our series of 45 patients with a minimum 5-year follow-up, clinical assessment was incorrect in 22.5% of cases (22% of the patients with negative bilateral biopsy of the superficial inguinal nodes developed metastases), and many of the complications (flap necrosis, lymphedema) occurring after inguinal lymphadenectomy contributed to a poorer quality of patient survival. A therapeutic approach to the management of regional lymph nodes in order to combat the carcinoma more effectively and improve patient survival quality is suggested.

Pharmacokinetic study of radiolabeled anti-colorectal carcinoma monoclonal antibodies in tumor-bearing nude mice.

Monoclonal antibodies (MoAbs) 17-1A and 19-9, which specifically bind human colorectal carcinoma (CRC) cells, were tested for their usefulness in localizing colorectal tumors in nude mice. One of the 131I-labeled MoAbs and an irrelevant 125I-labeled immunoglobulin of the same isotype were injected into nude mice simultaneously bearing a human CRC and a human melanoma. The percentage of the injected dose of antibody per gram of tissue, the CRC/tissue ratios of antibody distribution, and the localization indices were calculated at various time intervals (2 h to 9 days). For both MoAbs, labeling to a specific activity of 10 microCi/microgram by the iodogen method gave optimum immunoreactivity. The accumulation of MoAb 17-1A in CRC reached is maximum at 5 days and remained at this level for up to 9 days postinjection. For MoAb 19-9, which detects a circulating antigen shed by the tumor into the serum, the accumulation in the CRC was maximum at 24 h, and decreased thereafter. The CRC/organ ratios and localization indices for both MoAbs increased with time in the CRC tissue, but remained low and unchanged in the melanoma and normal tissues. Using F(ab')2 antibody fragments, faster kinetics with earlier maximum accumulation, higher tumor/organ ratios, and better localization indices were achieved than with intact MoAbs. The data obtained was useful in defining parameters which must be considered before radiolabeled MoAbs are used in cancer patients for diagnostic purposes.