Radiotherapy of gastric cancer with a three field combination: feasibility, tolerance, and survival.

From 1980 to 1984, forty-five patients suffering gastric cancer were irradiated with curative intent. Twenty-three were considered at high risk of recurrence after complete surgical resection (invasion of the serosa, lymph nodes and/or surgical margins); eleven were treated after partial resection, and for eleven others, the local extension precluded surgery. Radiotherapy combined two lateral fields (usually with wedge filters) and an anterior field. The planned dose was 40 to 50 Gy, according to the amount of residual disease and doses delivered to the major part of the liver and the right and left kidneys did not exceed 30, 5, and 18 Gy, respectively. For patients aged less than 71 and whose general condition was acceptable, one cycle of chemotherapy (FAM for 20 patients and 5-FU for 10) preceded irradiation, followed if possible by 6 other cycles. Adverse effects, essentially anorexia, vomiting, and weight loss, led to definitively stopping irradiation in 8 cases, and were present in 21 other patients. Mean weight loss was 2.5 kg. Apart from one patient who developed a subphrenic abcess and died after reoperation, there was neither chronic complication, nor radiation hepatitis or nephritis. For 34 patients, the observation time was superior to 3 years: 23 died of their cancer, 1 of a subphrenic abcess, and 2 of an intercurrent disease. Eight were disease-free at 3 years (three of these were irradiated for macroscopic disease). For the overall series, the 4-year survival rate is 23%. There is a significant survival advantage for females versus males (p less than 0.01), a non-significant tendency in favor of microscopic residual disease versus macroscopic, and no advantage for the combination with FAM compared with no chemotherapy (non-randomized). This technique appears feasible with an acceptable tolerance and can control local tumor in a few cases. The planned dose of 40 Gy was probably too small and we are now testing 45 Gy delivered over the large initial volume, and boosts of 10-15 Gy to residual disease.

Fractionated radiation therapy in the treatment of stage III and IV cerebello-pontine angle neurinomas: preliminary results in 20 cases.

From January 1986 to March 1989, 20 patients with stage III and IV cerebello-pontine angle neurinomas were treated with external fractionated radiation therapy; seven patients had phacomatosis. Indications for radiation therapy were as follows: (a) poor general condition or old age contraindicating surgery, 10 patients; (b) hearing preservation in bilateral neurinomas after contralateral tumor removal, 5 patients; (c) partial resection or high risk of recurrence after subsequent surgery for relapse, 4 patients; (d) non-surgical relapse, 1 patient. Most patients were irradiated with a 9 MV linear accelerator. A 3 to 4-field technique with 5 x 5 cm portals was used. Doses were calculated on a 95% isodose and were given 5 days a week for a mean total dose of 5140 cGy (180 cGy/fraction). Median follow-up from radiation therapy was 30 months (7 to 46); 4 patients died, 2 with progressive disease. Two patients underwent total tumor removal after radiation therapy (1 stable and 1 growing tumor). On the whole, 14 tumors remained stable, 3 decreased in size, and 3 progressed. CT scan or NMR tumor changes consistent with partial tumor necrosis appeared in four cases. Hearing preservation was obtained in 3/5 hearing patients with phacomatosis. When surgery is not indicated or incomplete, fractionated radiation therapy appears to be an effective and well-tolerated treatment for stage III and IV neurinomas. Hearing can be preserved.

Fractionated radiation therapy in the treatment of stage III and IV cerebello-pontine angle neurinomas: long-term results in 24 cases.

PURPOSE: To reevaluate long-term results of fractionated radiation therapy (RT) in a previously published series of cerebello-pontine angle neurinomas (CPA). METHODS AND MATERIALS: From January 1986 to May 1992, 24 patients with Stage III and IV CPA neurinomas were treated with external fractionated RT; 7 patients had phacomatosis. One patient was irradiated on both sides and indications for radiotherapy were as follows: (a) poor general condition or old age contraindicating surgery, 14 cases; (b) hearing preservation in bilateral neurinomas after contralateral tumor removal, 5 cases; (c) partial resection or high risk of recurrence after subsequent surgery for relapse, 4 cases; (d) nonsurgical relapse, 2 cases. Most patients were irradiated with 9 MV photons. A three- to four-field technique with coned-down portals was used. Doses were calculated on a 95% isodose and were given 5 days a week for a mean total dose of 51 Gy (1.80 Gy/fraction). RESULTS: Median follow-up from RT was 60 months (7 to 84); five patients died, two with progressive disease. Two patients underwent total tumor removal after RT (one stable and one growing tumor). On the whole, tumor shrinkage was observed in 9 patients (36%), stable disease in 13 (52%), and tumor progression in 3. Hearing was maintained in 3 out of 5 hearing patients with phacomatosis. CONCLUSION: Fractionated RT appears to be an effective and well-tolerated treatment for Stage III and IV CPA neurinomas. Hearing can be preserved for a long time.

Radiotoxic model for three-dimensional treatment planning. Part 1: Theoretical basis.

Since recent treatment planning systems calculate volumetric dose distribution, an objective evaluation of potential toxicity in the main critical organs may be helpful in treatment optimization. Modeling the toxicity of radiotherapy must at least account for: (a) specific risks in every critical organ; (b) total dose and dose per fraction; (c) partial irradiation of critical organs; (d) heterogeneous dose distribution. The Radiation Damage Factor formula is aimed at estimating the delayed toxicity of a given treatment plan on every critical organ concerned. The formulation uses a double exponential function: RDF = 100 e-Ke-(a+bd)DVc, where: D is the total dose, and d the dose per fraction; a and b are coefficients representing the radiosensitivity of the critical organ, according to the linear-quadratic model, with a/b = alpha/beta. K represents the theoretical critical unit content of the organ, these critical units being groups of functionally related stem cells. The avoidance of a complication depends on the ability of surviving critical units to preserve organ function. V is the ratio:irradiated volume/total volume of the organ. Exponent c accounts for tissue organization: c is equal to or near 1 in "parallel organs" like the liver or the lung, where localized hot spots are tolerated; c is lower in "series organs" like the spinal cord where hot spots, even in a small portion, are dangerous. Heterogeneous irradiation, summarized by dose cumulative-volume histograms, is accounted for by calculating step by step the dose D' considered as having an equivalent effect when given in the largest irradiated volume ratio. Preliminary calibration of the RDF formula is attempted for radiation myelitis and radiation hepatitis.

Fractionated radiation therapy in the treatment of intracranial meningiomas: local control, functional efficacy, and tolerance in 91 patients.

PURPOSE: To evaluate efficacy and tolerance of external fractionated radiation therapy (RT) in the treatment of intracranial meningiomas. METHODS AND MATERIALS: From January 1981 to September 1993, 91 patients with intracranial meningiomas were treated with fractionated RT. Indications were as follows: (a) incomplete surgical resection, 29 patients; (b) tumor recurrences without considering the amount of the second resection, if performed, 14 patients; (c) completely excised angioblastic, aggressive benign, and anaplastic tumors, 8 patients; (d) medically inoperable and basilar tumors where operation would involve considerable danger or permanent neurological damage, 44 patients. Most patients were irradiated with 6 to 9 MV photon beams. A three- to four-field technique with coned-down portals was used. Doses were calculated on the 95% isodose and were given 5 days a week for a median total dose of 52 Gy (1.80 Gy/fraction). RESULTS: Median follow-up from radiation therapy was 40 months. Acute tolerance was excellent, but there were six late delayed injuries. Tumor recurrences occurred in six cases. Six patients died from their tumor or RT complications, 19 from nontumoral reasons. Three, 5- and 10-year survival rates were 82, 71, and 40%, respectively. The most significant prognostic factor was age: 5-year survival rate was 86% for patients less than 65 years and 37% for patients more than 65. However, there were no differences in recurrence-free survival rates between patients younger than 65 and the oldest ones. Of 60 symptomatic patients with neurological deficits, 43 had neurological improvement (72%), beginning in some cases within 15 to 20 days after starting RT. CONCLUSION: These results reassess the role of fractionated RT in the treatment of meningiomas, and stress on its efficacy, especially on cranial nerves palsies, without severe toxicity in most cases.

Results of surgical treatment of T3 and T4 tumors of the oral cavity and oropharynx.

The combined use of surgery and radiotherapy is commonly accepted as the most effective treatment for locally advanced head and neck cancers. T3 and T4 tumors of the oral cavity and oropharynx often necessitate extensive local surgery. From 1981 to 1988, 199 patients with T3 and T4 tumors of the oral cavity and oropharynx were treated. One hundred seventeen patients underwent surgery plus postoperative radiotherapy; 78 had flap reconstructions. This series is extremely homogeneous because surgery was always performed by two surgeons, whereas radiotherapy was the responsibility of the same physician. The results of this study show a 96% local control rate at the end of treatment among the patients with combined treatment. The average time by which hospitalization was prolonged due to surgery was 29 days. The type and delay of recurrences and survival in relation with node involvement are also discussed. Extensive surgery in association with radiotherapy remains a reliable treatment in such patients.

Neuropsychologic impairment in adults with brain tumors.

Neuropsychologic studies were performed in 49 adult patients with primary intracranial tumors following surgery and radiation therapy. In the absence of computed tomography (CT) scan evidence of tumor recurrence or neurologic disorders, patients' intellectual functioning was tested once (49 patients), twice (18 patients), or three times (5 patients) by the Wechsler Intelligence Scale (WAIS) between 1.5 and 110 months after the beginning of irradiation. Full scale IQ (FSIQ) and deterioration coefficient (DC) were evaluated. Time elapsed from treatment to initial evaluation (vertical study) determined three statistically different patient groups. During the first 4 months, DC and FSIQ did not differ from a normal population. From 5 to 30 months, there appeared a significant probability of intellectual deterioration (p = 0.01), whereas median FSIQ remained at a normal level. Beyond 30 months, deterioration disappeared in terms of DC, but median FSIQ fell (p = 0.01). Second and third evaluations (horizontal study) confirmed the initial evaluation. Nevertheless, later recovery from FSIQ impairment was seen in 4 of 5 patients who were less than 30 years old and in 2 patients between 30 and 50 years of age who returned to work early after treatment. We believe that early neuropsychologic testing to detect early psychologic impairment is needed in all adult patients treated for brain tumors, especially in younger patients. Psychologic assistance and an early return to work may be beneficial.

A randomized study of bolus fluorouracil plus folinic acid versus 21-day fluorouracil infusion alone or in association with cyclophosphamide and mitomycin C in advanced colorectal carcinoma.

From May 1988 to June 1992, 129 eligible patients suffering from measurable advanced colorectal cancer were enrolled in a randomized study comparing bolus fluorouracil plus leucovorin (FU-FA); continuous fluorouracil infusion (FU-cont); FUcont plus cyclophosphamide and mitomycin C (FUMIC). FU-FA consisted of weekly fluorouracil (FUra) bolus (600 mg/m2) 1 hour after the initiation of a 2-hour infusion of 500 mg/m2 of leucovorin, for 6 weeks every 8 weeks. FUcont patients were planned to receive 400 mg/m2/day FUra infusion, for 21 days every 28 days. In FUMIC patients, FUcont was associated with weekly cyclophosphamide bolus (300 mg/m2) and monthly mitomycin C bolus (10 mg/m2). Quality of life was evaluated using six linear analogue scales, completed by the patient. Accrual in the FUMIC arm was stopped after the 25th patient because of toxicity. The response rates were 22 of 48 (45.8%) with FUcont and 13 of 52 (25%) with FU-FA (P = .048). Progression-free survival (median: 8 v 4.4 months; P = .0026) and overall survival (median: 12.9 v 9.6 months; P = .028) were significantly greater for the FUcont arm compared with the FU-FA arm. Toxicity was observed in 62% of the FUcont patients (grade 3-4: 10%), mainly hand-foot syndrome, diarrhea, mucositis, and mainly gastrointestinal in 69% of the FU-FA patients (grade 3-4: 11.6%). Linear analogue scales exploring quality of life, available for the first 6 months, gave similar scores in FU-FA and FUcont patients. We conclude that this FUcont schedule, achieving high FUra dose-intensity, offers significant advantages, in terms of response and survival, over weekly FUra plus leucovorin.

[An intensive course for general practitioners in a university hospital for oncology. Evaluation of a 5-year experience]. / Stage intensif pour des médecins généralistes en service hospitalo-universitaire de cancérologie. Bilan d'une expérience de 5 ans.

For 5 years, 121 general practitioners (GP) had a one-week course of continuing medical education, organized by the League against cancer, by groups of five, in oncology university services. A few years later they were asked, through a postal questionnaire, about their appreciation of this course and its consequences on their practice. Seventy six (55%) answers indicate that, except for two GP, such a course was considered as very valuable. They think it was useful to improve their clinical expertise and to reduce radiological and biological investigations. Their relations with patients, families and oncologists had been improved. They hope such an experiment will continue. Limits and difficulties of this experiment are briefly underlined.

[Probable effect of cerebral irradiation on intellectual efficiency]. / Incidence probable de l'irradiation cérébrale sur l'efficience intellectuelle.

Thirty adult patients treated for brain tumors by radiation therapy were tested by the Weschler intelligence scale (WAIS). All patients were in complete clinical and scanographic remission. Intellectual quotient (IQ) and deterioration coefficient were evaluated. This coefficient was determined by separate study of intellectual faculties according to their relationship to external aggressions. During the first six months, IQ and deterioration coefficient are similar to those observed in the normal population. From 7 to 30 months, there is a significant diminution of the intellectual faculties (p = 0,01) noted on the deterioration coefficient but without global IQ alteration. After 30 months appears a decrease in the global IQ, testifying of further alteration of intellectual faculties. Radiation therapy seems to be the predominant factor in the induction of this deterioration and the importance of the irradiation volume appears to be essential. On the other hand, neurosurgery, chemotherapy and emotional status seem to be less important. Intellectual deterioration makes professional reinsertion difficult but not impossible. Further studies are necessary to define what place take other factors like age, vascular status, tumor site, type and number of chemotherapy cycles, acute radiation tolerance, in the induction of this deterioration.

[Target volume in radiotherapy of gastric adenocarcinoma]. / Les volumes-cibles de la radiothérapie des adénocarcinomes gastriques.

UNLABELLED: The spread of gastric adenocarcinoma may follow three main patterns: hematogenic, lymphatic and intraperitoneal. A GTV should be considered in preoperative or exclusive radiation therapy. After non-radical surgery, a "residual GTV" will be defined with the help of the surgeon. The CTV encompasses three intricated volumes. a) A "tumor bed" volume. After radical surgery, local recurrences appear as frequent as distant metastases. The risk depends upon the depth of parietal invasion and the nodal status. Parietal infiltration may extend beyond macroscopic limits of the tumor, especially in "linitis plastica". Therefore this volume will include: the tumor and the remaining stomach or their "bed of resection", a part of the transverse colon, the duodenum, the pancreas and the truncus of the portal vein. In postoperative RT, this CTV also includes the jejuno-gastric or jejuno-esophageal anastomosis. b) A peritoneal volume. For practical purposes, two degrees of spread must be considered: (1) contiguous microscopic extension from deeply invasive T3 and T4 tumors, that remain amenable to local sterilization with doses of 45-50 Gy, delivered in a CTV including the peritoneal cavity at the level of the gastric bed, and under the parietal incision; (2) true "peritoneal carcinomatosis", with widespread seeds, where chemotherapy (systemic or intraperitoneal) is more appropriate. c) A lymphatic volume including the lymph node groups 1 to 16 of the Japanese classification. This volume must encompass the hepatic pedicle and the splenic hilum. In proximal tumors, it is possible to restrict the lower part of the CTV to the lymphatic volume, and therefore to avoid irradiation of large intestinal and renal volumes. In distal and proximal tumors, involvement of resection margins is of poor prognosis--a radiation boost must be delivered at this level. The CTV in tumors of the cardia should encompass the lower part of the thoracic esophagus and the corresponding posterior mediastinum. In tumors invading the distal esophagus, a more complete coverage of mediastinal lymph nodes should be considered, especially in patients in good general condition. In tumors of the gastric fundus, most of the left hemidiaphragm should be included, as well as the spleen and its hilum (or their resection bed). In proximal tumors without involvement of the lesser curvature, a full coverage of the hepatic pedicle is not necessary. In contrast, for distal tumors, the hepatic pedicle and the hepatoduodenal ligament should be included whereas the splenic area could be spared. CONCLUSION: Planning the treatment of gastric cancer remains difficult; target volumes must be customized by experienced radiation oncologists according to tumoral and clinical situation.

[Volume-effect and radiotherapy [II]. Part II: volume-effect and normal tissue]. / Effet volume en radiothérapie [II]. Deuxième partie : volume et tolérance des tissus sains.

The first part of our work has focused on the relationship between tumor volume and tumor control. Indeed, it is well known that the importance of irradiated volume could be a main parameter of radiation-induced complications. Numerous mathematical models have described the correlation between the irradiated volume and the risk of adverse effects. These models should predict the complication rate of each treatment planning. At the present time late effects have been the most studied. In this report we firstly propose a review of different mathematical models described for volume effect. Secondly, we will discuss whether these theoretical considerations can influence our view of radiation treatment planning optimization.

[Conformal therapy of locally advanced cholangiocarcinoma of the main bile ducts]. / Radiothérapie conformationnelle des cholangiocarcinomes de la voie biliaire principale localement évolués.

PURPOSE: Retrospective study of 23 patients treated with conformal radiotherapy for a locally advanced bile duct carcinoma. PATIENTS AND METHODS: Eight cases were irradiated after a radical resection (R0), because they were N+; seven after microscopically incomplete resection (R1); seven were not resected (R2). A dose of 45 of 50 Gy was delivered, followed by a boost up to 60 Gy in R1 and R2 groups. Concomitant chemotherapy was given in 15 cases. RESULTS: Late toxicity included a stenosis of the duodenum, and one of the biliary anastomosis. Two patients died from cholangitis, the mechanism of which remains unclear. Five patients are in complete remission, six had a local relapse, four developed a peritoneal carcinosis, and six distant metastases. Actuarial survival rate is 75%, 28% and 7% at 1, 3 and 5 years, respectively (median: 16.5 months). Seven patients are still alive with a 4 to 70 months follow-up. Survival is similar in the 3 small subgroups. The poor local control among R0N+ cases might be related to the absence of a boost to the "tumor bed". In R1 patients, relapses were mainly distant metastases, whereas local and peritoneal recurrences predominated in R2. CONCLUSION: Conformal radiochemotherapy delivering 60 Gy represents a valuable palliative approach in locally advanced biliary carcinoma.

[Volume-effect in radiation therapy part one: volume-effect and tumour]. / L'effet volume en radiothérapie première partie: effet volume et tumeur.

Volume is an important parameter of radiation therapy. Local control is inversely related to tumor size and the complication rate increases with the importance of the irradiated volume. Although the effect of irradiated volume has been widely reported since the beginning of radiotherapy, it has been less studied than other radiation parameters such as dose, fractionation, or treatment duration. One of the first organ system in which the adverse effect of increased volume was well defined is the skin. Over the last twenty years, numerous mathematical models have been developed for different organs. In this report we will discuss the relation between irradiated volume and tumor control. In a second article we will study the impact of irradiated volume on radiation adverse effects.

[Practice of virtual simulation at the Saint-André hospital]. / Pratique de la simulation virtuelle à l'hôpital Saint-André.

PURPOSE: Prospective evaluation of a virtual simulation technique. PATIENTS AND METHODS: From September 1993 to February 1997, 343 patients underwent radiation therapy using this technique. Treated sites were mostly: brain (132), rectum (59), lung (43), and prostate (28). A CT-scan was performed on a patient in treatment position. Twenty-five to 70 jointive slices widely encompassed the treated volume. The target volume (CTV according to ICRU 50) and often critical organs were controured, slice by slice, by the radiation oncologist. Beams covering the CTV plus a security margin (PTV) were placed on the "virtual patient". Digital radiographs were reconstructed (DRR) as simulator radiographs for each field. Thus, the good coverage of PTV was assessed. Fields and beam arrangements were further optimized. Definitive isocenter was then placed using a classical simulator. Perfect matching of DRR and actual simulator radiographs had to be obtained. RESULTS: Nineteen patients presented grade 3, and 1 grade 4 acute radiation effects. With a median follow-up of 18 months, five patients suffered from grade 3, and one from grade 4 complications. Fifty-five patients had tumor recurrence in the treated volume, and 19 had marginal relapse. CONCLUSION: In our department, virtual simulation has become a routine technique of treatment planning for deep-seated tumors. This technique remains time-consuming for radiation oncologists: about 2 hours. But it stimulates reflexion on anatomy, tumor extension pathways, target volumes; and is becoming an excellent pedagogical tool.

[Central nervous system. Experience of the Bordeaux University Hospital Center and review of the literature]. / Les dysgerminomes du système nerveux central. Expérience du Centre Hospitalier Universitaire de Bordeaux et analyse de la littérature.

PURPOSE: Retrospective analysis of 17 patients with intracranial germ cell tumors treated in a multidisciplinary consultation at the Bordeaux University Hospital a and literature review. MATERIALS AND METHODS: Seventeen consecutive patients were treated from 1978 to 1995 for a primary intracranial germ cell tumor. Median age was 14 (range 3-29 years). There were two malignant teratoma, six proved germinoma and nine presumed germinoma (diagnostic based on biological, radiological and treatment criteria). All received radiotherapy from 30 to 60 Gy (median 40 Gy) in different volumes. Chemotherapy was administered in 15 cases, three after surgery and 12 after radiotherapy. RESULTS: All tumours were in complete remission after initial treatment. The two malignant teratomas recurred in non-irradiated area after nine and 48 months, and the patients died. None of the germinoma recurred within a follow-up period of two to 17 years (median 65 months). Five and 10 year actuarial overall survival rates were the same: 84% for all histologies and 100% for germinomas. Only two patients developed school difficulties and six presented an hypopituitarism, of which one was consecutive to radiotherapy. Chemotherapy was well tolerated. CONCLUSION: This retrospective study and literature analysis are in favor of limited dose and volume of radiation therapy associated with chemotherapy.

[Fractionated irradiation of cerebellopontine angle neurinoma: 12 years' experience of the Bordeaux University Hospital Center]. / Irradiation fractionnée des neurinomes de l'angle pontocérébelleux: 12 ans d'expérience au centre hospitalier universitaire de Bordeaux.

PURPOSE: To evaluate retrospectively the long-term results of fractionated radiation therapy (RT) in cerebello-pontine angle neurinomas (CPA). METHODS AND MATERIAL: From January 1986 to October 1995, 29 patients with stage III and IV neurinomas were treated with external fractionated RT. One patient was irradiated on both sides and indications for RT were as follows: (1) general contraindications for surgery (16 patients); (2) hearing preservation in bilateral neurinomas after controlateral tumor exeresis (six patients); (3) partial tumor removal (five patients); and, (4) non-surgical recurrence (three patients). A three to four fields technique with coplanar static beams and conformal cerobend blocks was used; doses were calculated on a 95 to 98% isodoses and were given five days a week for a median total dose of 51 Gy (1.8 Gy/fraction). Most patients were irradiated with 6 to 10 MV photons). RESULTS: Median follow-up was 66 months (seven to 120 months). Seven patients died, two with progressive disease, five from non-tumoral causes. Tumor shrinkage was observed in 13 patients (43.3%), stable disease in 14 (46.6%), and tumor progression in three. Two patients underwent total tumor removal after RT (one stable and one growing tumor). Hearing was preserved in four out of six patients. No patient experienced facial or trigeminal neuropathy. CONCLUSION: Fractionated RT is a well tolerated and efficacious treatment of large non-surgical CPA neurinomas.

[Fractionated radiotherapy of intracranial meningiomas: 15 years' experience at the Bordeaux University Hospital Center]. / Radiothérapie fractionnée des méningiomes intracrâniens: 15 ans d'expérience au centre hospitalier universitaire de Bordeaux.

PURPOSE: To evaluate the long-term results of external fractionated radiation therapy (RT) in the treatment of intracranial meningiomas. PATIENTS AND METHODS: From January 1981 to December 1996, 156 patients with intracranial meningiomas were treated with external fractionated RT. Median age was 57. Indications for radiation therapy were as follows: (1) completely excised histologically aggressive tumors (12 patients); (2) incomplete surgical resection (37 patients); (3) medically inoperable or basilar tumors where operation would involve considerable danger or permanent neurological damage (77 patients); and, (4) tumor recurrences (30 patients). Most patients were irradiated with 6 to 9 MV photon beams. A three to four-field technique with coned-down portals was used. Since 1993, 71 patients had a three dimensional dosimetry. Doses were calculated on the 95% or 98% isodoses, all fields were treated every day, five days a week, for a median total dose of 50 Gy (1.8 Gy/Fraction). RESULTS: Median follow-up from radiation therapy was 40 months. Acute tolerance was excellent; an early clinical improvement during radiation therapy was noted in 19 patients (17.8%). Clinical improvement or stabilization was observed in 130 patients (83.4%). Radiologically, local control was obtained in 124 cases (79.4%) and tumor recurrences occurred in 21 cases (ten progressions in the treated volume, five borderline, six new locations). Overall and cause specific-survival rates were 75% and 89% at five years, and 45 and 76% at 10 years, respectively. CONCLUSION: These results reassess the role of fractionated RT in the treatment of intracranial meningiomas. Long-term tolerance is excellent for a majority of patients. The study of recurrences confirms the importance of the definition of the target volume, and asks questions about total given doses.

[Upper extremity deep venous thrombosis. 40 hospitalized patients]. / Thromboses veineuses profondes des membres supérieurs: à propos de 40 patients hospitalisés.

Deep venous thrombosis is 50 times less frequent in upper than in lower limbs. Data remain poor in the literature. Forty consecutive patients (24 males, 16 females, mean age: 54.5 years) were retrospectively analysed from 161 subjects who underwent venous explorations of the upper extremity for a 3.5 year period in the same center. Diagnosis of thrombosis was made by duplex ultrasonography (n =37) or phlebography (n =3). Main clinical manifestations were edema (n =36) and pain (n =29). Location of thrombosis was humeral (n =1), axillary (n =2), or sub-clavian (n =37, 2 bilateral). The majority of thrombosis (n =29) were secondary to cancer and venous catheter (n =19, 15 implanted ports), to central catheter alone (n =3) or cancer alone (n =7). The 11 others were associated with thoracic outlet syndrome (n =6) or apparent primary thrombosis (n =5). Thrombophilia was identified in 6 out of these 11. During follow up [mean of 9 months (0,5-36)], two patients developed pulmonary embolism, 14 a post-thrombotic syndrome and 16 patients died. Initial therapy included heparin (n =36) or fibrinolysis (n =4). Upper extremity deep venous thrombosis are mostly associated with cancers and venous catheters. Thrombophilia is frequent in the other cases. Heparin followed by oral anticoagulation is the optimal therapy whose duration depends upon underlying condition. Fibrinolysis has not been useful for preventing post-thrombotic syndrome in our study.

[Adenocarcinoma of the exocrine pancreas: management and therapeutic hopes]. / L'adénocarcinome du pancréas exocrine: prise en charge et espoirs thérapeutiques.

INTRODUCTION: Pancreatic carcinoma is a major public health concern, as it kills more than 6,000 people each year in France. CURRENT KNOWLEDGE AND KEY POINTS: The main risk factor demonstrated by concordant case-control studies is cigarette smoking. Pancreatic carcinoma is generally diagnosed at an advanced stage. Results of radical surgery are still poor. In most of the reported series, less than 25% of the patients survive at five years. FUTURE PROSPECTS AND PROJECTS: Postoperative radiochemotherapy slightly increases the hope of cure. In locally advanced tumors, radiochemotherapy, sometimes preoperative, allows some patients to survive more than two years. Though results of palliative chemotherapy remain very poor, some clinical benefit has been observed in randomized trials comparing this treatment with the currently best supportive treatment.