A randomized clinical trial of adjuvant chemotherapy with doxorubicin, ifosfamide, and cisplatin followed by radiotherapy versus radiotherapy alone in patients with localized uterine sarcomas (SARCGYN study). A study of the French Sarcoma Group.

BACKGROUND: There is no proven benefit of adjuvant treatment of uterine sarcoma (US). SARCGYN phase III study compared adjuvant polychemotherapy followed by pelvic radiotherapy (RT) (arm A) versus RT alone (arm B) conducted to detect an increase ≥ 20% of 3-year PFS. METHODS: Patients with FIGO stage ≤ III US, physiological age ≤ 65 years; chemotherapy: four cycles of doxorubicin 50 mg/m² d1, ifosfamide 3 g/m²/day d1-2, cisplatin 75 mg/m² d3, (API) + G-CSF q 3 weeks. Study was stopped because of lack of recruitment. RESULTS: Eighty-one patients were included: 39 in arm A and 42 in arm B; 52 stage I, 16 stage II, 13 stage III; 53 leiomyosarcomas, 9 undifferenciated sarcomas, 19 carcinosarcomas. Gr 3-4 toxicity during API (/37 patients): thrombopenia (76%), febrile neutropenia (22%) with two toxic deaths; renal gr 3 (1 patient). After a median follow-up of 4.3 years, 41/81 patients recurred, 15 in arm A, 26 in arm B. The 3 years DFS is 55% in arm A, 41% in arm B (P = 0.048). The 3-year overall survival (OS) is 81% in arm A and 69% in arm B (P = 0.41). CONCLUSION: API adjuvant CT statistically increases the 3 year-DFS of patients with US.

[Is staging bone scan useful in patients with small invasive breast carcinoma?]. / Faut-il réaliser une scintigraphie osseuse dans le bilan d'extension des cancers du sein de petite taille?

We conducted a retrospective study including 517 patients with invasive breast cancer classified pT1 less than 20mm. We estimated the relevance of bone scan in the screening of metastases at the time of primary presentation, as well as the costs incurred by such a screening. Postoperative systematic bone scan did not detect the two cases of synchronous bone metastases in this population. No bone metastasis was detected in groups with the highest metastatic risks (low profitability for all pT1 classified cancers). Bone scan's rate of false positive was high (17%). The global cost was estimated at 110,770 euros, that was 215 euros per patient (208 to 232 euros in the risk groups).

[Documentation management: from theory to practice]. / La gestion documentaire: de la théorie à la pratique.

The management of the documentation is one of the key points regarding the efficacy and the performance of the quality management of health centres. It offers to all professionals the possibility to be informed on the procedures in use, leading to a pool of documents for improvement of organisations and for securing the critical steps of the patient management. In this paper, we will describe the optimal organisation of the documentation according to Haute autorité de santé (HAS) and ISO recommendations, then we will discuss in concrete terms the potential methods usable for the production of a tool well adapted to our routine practice, in order to achieve the objectives for security.

Evaluation at 3 years of concurrent bevacizumab and radiotherapy for breast cancer: Results of a prospective study.

PURPOSE: To determine the 3 years late toxicity among patients with non-metastatic breast cancer who received concurrent bevacizumab and locoregional radiotherapy. MATERIAL AND METHODS: This is a single-arm, multicentre, prospective study, of the toxicity of adjuvant concomitant association of bevacizumab and radiotherapy in patients with breast cancer. Toxicity was assessed by the Common Terminology Criteria for Adverse Events version 3.0 during the radiotherapy and follow-up clinics at 12 and 36 months after its completion. The study was designed to evaluate the toxicity at one year, 3 years and 5 years. RESULTS: Sixty-four patients were included from October 2007 to August 2010. All of them received concurrent adjuvant radiotherapy and bevacizumab (in 24 cases after primary systemic treatment). All patients received non-fractionated radiotherapy to breast or chest wall with or without irradiation of regional lymph nodes. Early toxicity has been previously reported. Median follow-up was 46.4 months (range: 18-77 months). Median age was 53 years old (range: 23-68 years). The 3-years overall survival was 93% (range: 87-100%). Evaluation of the toxicity at 3 years was available for 67% of the patients. There was a low rate of toxicity: 14% grade 1 pain, 9% grade 1 fibrosis, 2% grade 1 telangiectasia, 2% grade 1 paresis, 7% grade 1 lymphedema and 2% grade 3 lymphedema. No grade 4 toxicity was observed. No patient had a left ventricular ejection fraction below 50% at 3 years. CONCLUSIONS: Concurrent bevacizumab with locoregional radiotherapy is associated with acceptable 3-years toxicity in patients with breast cancer.

Stereotactic body re-irradiation therapy for locally recurrent prostate cancer after external-beam radiation therapy: Initial report.

PURPOSE: Management of prostate cancer relapses after external-beam radiation therapy is still undefined. Re-irradiation schedules have been explored in different tumour sites. In this report, we present our preliminary experience of re-irradiation using stereotactic body radiotherapy for localized prostate cancer failure. MATERIAL AND METHODS: Between March 2011 and October 2014, robotic stereotactic body radiation therapy was administered to patients previously treated with external-beam radiation therapy to a median dose of 71.1Gy (range, 45-76.5Gy) and with biochemical failure corresponding to a local in-field recurrence of prostate cancer. Ten patients had recurrences after postoperative external-beam radiotherapy. Patients underwent a pelvic MRI to confirm the recurrence and a total body staging using a ((18)F)-fluorocholine PET/CT. The prescription dose consisted of five fractions of 7.25Gy to a total dose of 36.25Gy. Efficacy was evaluated based on biochemical response and toxicity was evaluated according to CTCAE v.4.0 questionnaires and International Prostate Symptom Score. RESULTS: Twenty-one patients were treated and followed for a median time of 11.7 months (mean: 13.4 months; range: 2.5-46.5 months). Median time between the first external-beam radiation therapy of prostate cancer and the first day of CyberKnife(®) treatment was 111 months (range: 38-398 months). One-year biochemical recurrence-free survival rate was 83.3%, and only one in-field progression was reported. Two patients had a biochemical failure corresponding to metastatic progression without evidence of local recurrence. Treatment was well tolerated, with only one grade 2 acute genitourinary toxicity, no grade≥2 acute gastrointestinal or late toxicities were reported. CONCLUSION: Stereotactic body re-irradiation therapy using CyberKnife(®) after failed external-beam radiation therapy showed favourable results in terms of in-field local and biochemical control. Toxicity was low and acceptable. Further prospective studies are needed to confirm these results to select patient and to evaluate the introduction of androgen-deprivation therapy.

[Acute skin toxicity in breast intensity modulated radiotherapy using field in field technique]. / Toxicité aiguë cutanée de l'irradiation mammaire avec modulation d'intensité avec technique de champ dans le champ (optimisation avec pré-segmentation).

PURPOSE: The optimization with presegmentation irradiation technique (Dosisoft™), used in treatment of breast carcinomas, facilitates the treatment delivery and improves radioprotection. The objective of our study was to evaluate the potential impact of this innovative technique on the acute skin toxicity especially on the rate of moist desquamation during irradiation of the whole breast after conservative surgery. PATIENTS AND METHODS: The scores of acute skin toxicity observed at 50 Gy in 103 patients treated with the presegmentation technique were compared to those of 101 patients with similar breast size treated with a classic 3D technique. All patients received 50 Gy/2 Gy per fraction, 5 days a week using 4 MV photon beam. The boost on the tumoural bed was realized according to conventional technique. Using the NCI-CTCAE V4, the skin toxicity was recorded every week during the medical visit. Moreover, the following factors that could induce skin toxicity have been studied: breast size, body mass index, age, prior chemotherapy, concurrent administration of trastuzumab, hypertension, diabetes, smoking habits and statin uptake. RESULTS: The incidence of moist desquamation observed in all sites, has been decreased to only 9.8% in the presegmentation group versus 16.8% in the test group, the difference being not statistically significant OR=0.53 [0.23; 1.22] (P=0.13). In univariate analysis the presegmentation technique enabled a significant decrease of 4.4 Gy in mean, of the value of maximum dose (P=0.001). The other risk factors of skin toxicity are the increase of breast size (P<0.001), a high body mass index (P<0.001), hypertension (P=0.03) and concurrent administration of trastuzumab (P=0.07). In multivariate analysis, the two remaining significant factors are breast size (OR=1.004 [1.002; 1.006]) and trastuzumab administration (OR=4.95 [1.17; 20.79]). CONCLUSION: The comparison of the skin toxicity induced by the presegmentation or the reference technique shows a trend regarding the improvement of the skin tolerance when using the presegmentation technique, thus pleading in favour of its use considering its dosimetric interest and the improvement of radioprotection of the patient. The next step will consist to experiment the simultaneous boost on tumoural bed using this technique.

Late toxicities and outcomes of adjuvant radiotherapy combined with concurrent bevacizumab in patients with triple-negative non-metastatic breast cancer.

OBJECTIVE: To evaluate the safety of the concurrent combination of bevacizumab with adjuvant radiotherapy (B-RT) in breast cancer (BC). METHODS: Multicentre, prospective study, of the toxicity of adjuvant radiotherapy (RT) alone or B-RT in patients with non-metastatic BC enrolled in randomized Phase 3 BEATRICE trial. Early and late toxicities were assessed by the Common Terminology Criteria for Adverse Events v. 3.0 during and 12 months after the completion of RT. RESULTS: From 2007 to 2012, 39 females received adjuvant B-RT and 45 received adjuvant RT alone. Median follow-up was 21.5 months. All patients had triple-negative non-metastatic BC and received adjuvant chemotherapy followed by RT. 90% of the 39 females treated by concurrent B-RT received whole breast irradiation (WBI) with a boost and 4 (10%) received post-mastectomy RT. Lymph node RT was delivered in 49% of the females with internal mammary chain irradiation. The mean duration of bevacizumab was 11.7 months. 38 (84%) females treated by RT alone received WBI with a boost and 16% of the females received post-mastectomy RT. Lymph node RT was delivered in 47% of the females with internal mammary chain RT in 31%. Grade 3 acute dermatitis was observed in 9% of patients receiving B-RT and 5% of patients receiving RT alone with no significant difference. 1 year after the completion of RT, the most common late grade 1-2 toxicities in the B-RT group were pain (18%), fibrosis (8%) and telangiectasia (5%). CONCLUSION: The concurrent bevacizumab with locoregional RT is associated with acceptable early and late 1-year toxicities in patients with BC. ADVANCES IN KNOWLEDGE: The largest series of this association.

Enhanced acute toxicity in oropharynx carcinoma treated with radiotherapy and concomitant cisplatin, 5-fluorouracil and mitomycin C.

The aim of this study was to establish the feasibility of giving concomitant radiotherapy and 3 cycles of chemotherapy with cisplatin (CDDP), 5-fluorouracil (5-FU) and mitomycin C (MMC) in locally advanced inoperable oropharyngeal cancer. From March 1990 to September 1993, 27 male patients (mean age 55 years) were included in this study. 3 patients (11%) were T2N0, 19 (70%) T3 (T3N0: n = 9, T3N1: n = 1, T3N2: n = 5, T3N3: n = 4), and 5 (19%) T4 (T4N0: n = 1, T4N1: n = 1, T4N2: n = 2, T4N3: n = 1). All patients received conventional radiotherapy delivering 70 Gy in 35 fractions and 52 days, and three cycles of chemotherapy starting on day 1, 21 and 42 with CDDP 20 mg/m2 and 5-FU 400 mg/m2 day 1 to day 4, and MMC 10 mg/m2 day 1. With a mean follow-up of 34 months (17-59), 10 patients (37%) were alive and free of disease. Among the 17 other patients, 8 died of cancer. Crude locoregional control rate was 78%, and probability of local control at 1 and 2 years was 85 and 80%, respectively. One- and 2-year survival rates were 48 and 31%, respectively, for both overall and disease-free survival. Grade 3 or 4 mucositis occurred in 22 patients (81%); enteral feeding was necessary for 63%; mean weight loss was 5.7 kg. Grade > 2 thrombocytopenia occurred in 11 patients (41%), grade > 2 neutropenia in 8 patients (29%), grade > 2 anaemia in 4 patients (15%). Febrile neutropenia or aplasia occurred in 5 patients (19%). 2 patients (7%) died during treatment of haematological or infectious complications related to the treatment. Another patient died 1 month after treatment with grade 4 thrombocytopenia and septicaemia. In conclusion, a high complete response rate has been achieved with this concomitant chemo- and radiotherapy, but with severe digestive and haematological toxicity. Addition of MMC to 5-FU and CDDP might have been responsible for this increased toxicity. This therapeutic combination is therefore not routinely feasible.

Partial hypoxia as a cause of radioresistance in a human tumor xenograft: its influence illustrated by the sensitizing effect of misonidazole and hyperbaric oxygen.

While previous studies with three human tumor xenografts suggest that contact-resistance plays a major role in the response of these tumors to radiation, it remains possible that partial hypoxia may provide an alternate explanation. The present study was carried out to check this possibility by investigating the influence of misonidazole (MISO) and hyperbaric oxygen (HBO) on both the initial and distal components of the survival curves of HRT18 tumor cells. The effect of a challenge dose of radiation on the initial radioresistance of this tumor was also studied. To assess the effects of MISO and HBO, tumor cell survival was determined by excision assay in two groups of tumor-bearing mice, one given MISO (1 mg/g body weight, i.p.) 45 min before irradiation and the other exposed to HBO (3.5 bars). MISO treatment caused greater sensitization than HBO. The enhancement ratios at the 5.10(-1) level were 1.7 (MISO) and 1.7 (HBO); at the 10(-1) level, they were 1.6 (MISO) and 1.4 (HBO); while at 10(-2), they were 1.6 (MISO) and 1.4 (HBO). These two sensitizing effects favor the hypothesis that solid tumors contain a compartment of partially hypoxic cells. To study the effect of a challenge radiation dose on initial radioresistance, tumors were given a challenge dose of 8 Gy, followed 24-48 hr later by doses ranging from 2-12 Gy. The challenge dose did not modify the shape of the survival curve.

Carcinoma of the uterine cervix stage IB and early stage II. Prognostic value of the histological tumor regression after initial brachytherapy.

In our center limited centro pelvic invasive carcinomas of the uterine cervix (less than 4 cm) are treated with brachytherapy and surgery. With these therapeutic modalities no residual carcinoma was observed for 80% of the patients. The purpose of this study was to evaluate our results with this treatment, and to evaluate the prognostic value of the pathological status of the cervix. From 1976 to 1987 we have treated 115 patients with these modalities. Staging system used was the FIGO classification modified for Stage II (divided in early Stage II and late Stage II). Patients were Stage IB (70 cases) and early Stage II (45 cases); 60 Gy were delivered with utero vaginal brachytherapy before any treatment. Six weeks later a radical hysterectomy with pelvic lymphadenectomy was performed. Twenty-one patients with positive nodes received a pelvic radiotherapy (45 to 55 Gy). Local control rate was 97% (100% for Stage IB and 93% for early Stage II). Uncorrected 10-year actuarial survival rate was 96% for Stage IB and 80% for early Stage II patients. No treatment failure was observed for Stage IB patients. Ninety-two patients (80%) had no residual carcinoma in the cervix (group 1) and 23 patients (20%) had a residual tumor (group 2). The sterilization rate of the cervix was 87% for Stage IB tumors versus 69% for early Stage II, and was 82% for N- patients versus 68% for N+ patients. Ten year actuarial survival rate was 92% for group 1 and 78% for group 2 (p = 0, 1). Grade 3 complications rate was 6%. We conclude that brachytherapy + surgery is a safe treatment for limited centro pelvic carcinomas of the uterine cervix (especially Stage IB) and that pathological status of the cervix after brachytherapy is not a prognostic factor.

Prognostic significance of breast relapse after conservative treatment in node-negative early breast cancer.

The prognostic significance of local relapse after conservative treatment of early stage breast carcinoma has been controversial. To determine the incidence and the prognostic value of a breast relapse, we analyzed the results obtained in a series of patients with pT1pN0 presentation of breast carcinoma treated conservatively without adjuvant medical treatment. From 1976 to 1986, 202 patients with invasive breast carcinoma of less than 2 cm without lymph node involvement were treated with surgery and radiation therapy. The overall survival rate was 97.2% at 5 years. Locoregional relapses occurred in 16 patients (7.9%). In these patients, the overall survival rate was significantly decreased as compared to that of patients without local relapse (87.5% versus 98.3% at 5 years, p less than 0.001). The probability of remaining metastasis-free was also significantly decreased (80.2% vs 91.3%, p less than 0.001). Most relapses (94%) appeared at or close to the primary site. Salvage local treatment was possible in 14/16 patients (87.5%). Age, menopausal status, size and site of primary tumor, histological grade, and boost technique did not influence significantly the risk of local relapse occurrence. We concluded that the occurrence of a breast relapse after a successful local conservative treatment is a pejorative prognostic factor predictive of a high risk of distant metastasis development. There is a need to individualize factors that could allow discrimination of patients with a high probability of local relapse and subsequent metastasis.

Primary chemotherapy and radiosurgical breast-conserving treatment for patients with locally advanced operable breast cancers.

PURPOSE: The traditional surgical treatment for operable breast cancer larger than 3 cm is mastectomy. In order to avoid mutilating surgery, we administered primary chemotherapy to 80 patients with operable non metastatic large breast cancer T2 > 3 cm and T3, N0-N1. The purpose of the study was to evaluate the breast-conserving rate induced by this treatment strategy and determine if it is a safe alternative for women with locally advanced breast carcinomas that are responders to an induction chemotherapy. METHODS AND MATERIALS: The mean age was 50.1 years. Forty-three patients were T2 > 3 cm, 37 were T3. Twenty-six were N0 and 54 were N1. Mean tumor size was 5.4 cm. Patients were treated with three courses of the MVCF regimen (Mitoxantrone, Vindesin, Cyclophosphamide, and 5 Fluorouracil) every 4 weeks and then with a radiosurgical combination. RESULTS: The overall response rate to induction chemotherapy was 51% with 17.5% complete tumor regression. Twenty-one percent of the patients developed grade 3 or 4 chemotherapy toxic effects, all acceptable and reversible. Breast-conserving treatment was feasible in 42.5% (34/80). Twenty patients (25%) were treated with a radiosurgical combination (tumorectomy+radiation therapy), 14 (17.5%) with radiotherapy alone (external irradiation and brachytherapy). Age, tumor stage, histology, hormonal status, hormonal receptors rate had no influence on the frequency of the observed regressions. Isolated recurrences occurred in five patients, two conservatively treated and three treated with mastectomy. Metastatic relapses were observed in 20 patients (12% in the responders and 38.5% in the non responders to chemotherapy) (p < 0.02). Five-year actuarial survival was 73% and was significantly better for responders to the induction treatment. CONCLUSION: These results suggest that primary chemotherapy and radiosurgical breast conserving treatment is a safe alternative to mastectomy for patients with locally advanced operable breast cancer. The long-term benefit of this strategy must be evaluated in well designed controlled trials.

Radiotherapy with high dose rate brachytherapy boost and concomitant chemotherapy for Stages IIB and III esophageal carcinoma: results of a pilot study.

PURPOSE: Radiotherapy (RT) and concomitant chemotherapy (CT) is the standard treatment for non resectable esophageal cancer. Usual total radiation dose is 50 Gy. In order to enhance local control rate a Phase II study was initiated to evaluate the feasibility of a combined treatment with an external radiation dose of 60 Gy and three cycles of concomitant CT, using the three main active drugs (CDDP, 5 FU and MMC), followed by a high dose rate (HDR) brachytherapy delivering 10 Gy. METHODS AND MATERIALS: Fifty-three patients, 48 men and 5 women, were entered in this study. Stages were evaluated with CT scan and with endoscopic sonography. Fifteen were Stage IIB, 38 Stage III. Treatment consisted of conventional fractionated RT to a total dose of 60 Gy delivered with 2 Gy per fraction, one fraction per day and five fractions per week. The CT regimen was a combination of Cisplatinum (CDDP) 20 mg/m2 and 5 Fluorouracil (5FU) 600 mg/m2 continuous infusion, from days 1-4 Mitomycin C (MMC) was given at 6 mg/m2 on day 1. Three cycles were administered on days 1, 22, and 43. Brachytherapy was delivered one week after the end of external radiation therapy. RESULTS: Full radiation therapy dose was delivered for 94% of the patients. CT compliance, evaluated on the mean relative dose-intensity was 85% for CDDP, 81% for 5FU and 51% for MMC. Overall grade 3 and 4 WHO toxicity rates were 23% and 7%, respectively. Haematologic toxicity was the most limiting factor. One patient died from treatment toxicity. Local control rate at one year was 74%. Three-year actuarial survival rate was 27%. Distant metastasis was the main cause of treatment failure. Swallowing score was good for 75% of the patients. Stage, performance status and weight loss were prognostic factors. CONCLUSION: This regimen with high dose RT, HDR brachytherapy and concomitant CT is feasible; however, a high level of haematologic toxicity was observed with the CDDP, 5FU and MMC regimen. Despite a poor compliance with CT, treatment results are very encouraging for patients with locally advanced disease.

Preoperative or postoperative brachytherapy for patients with endometrial carcinoma stage I and II.

In endometrial carcinoma, vaginal vault brachytherapy is performed to improve the local control rate and to decrease vaginal recurrences. To assess the best chronology of this brachytherapy compared to surgery, we have retrospectively analyzed results of treatment of patients treated either with preoperative brachytherapy (60 Gy) and then radical hysterectomy with bilateral salpingo oophorectomy (RH-BSO) (Group 1), or with RH-BSO and then postoperative brachytherapy (60 Gy) (Group 2). There were one hundred twenty-one patients in Group 1 and 63 in Group 2. The mean age was 61.8 years in Group 1 and 64.3 in Group 2. In Group 1, 73% of the patients were Stage I, and 77.6% were in Group 2. The two groups were comparable for histological grading and depth of tumoral invasion into the myometrium. Brachytherapy was delivered with one uterine and two vaginal sources in Group 1 and with three vaginal sources in Group 2. Doses to the reference volume and to reference points were calculated according to ICRU recommendations. Brachytherapy data were similar in the two groups except reference volume, which was smaller in Group 2. Local control rate was 87% in Group 1 and 91% in Group 2. Distant metastasis occurred in 12% of patients in Group 1 and 9% in Group 2. The 5-year actuarial survival rate was 84% in Group 1 and 89% in Group 2. Regarding stage, histological grading, and depth of tumoral invasion, no differences were observed between the two therapeutic groups. The only prognostic factor in the entire population was Stage. The 5-year actuarial survival rate was 91% for Stage I patients and 69% for Stage II (p value less than 0.03). The late severe complication rate was 14% in Group 1 and 7.9% in Group 2, a difference which was not statistically significant. We concluded that since no differences were observed between the two techniques, vaginal brachytherapy should be performed postoperatively when surgery is the first treatment (Stage I or II, grade 1 or 2, and no deep tumoral invasion into the myometrium).

Preoperative radiotherapy (RT) for rectal cancer: predictive factors of tumor downstaging and residual tumor cell density (RTCD): prognostic implications.

PURPOSE: To determine predictive factors and prognostic value of tumor downstaging and tumor sterilization after preoperative RT for rectal cancer. METHODS AND MATERIALS: Between 1977 and 1994, 167 patients with a histologically proven adenocarcinoma (70 T2, 65 T3, 29 T4, and 3 local recurrences) underwent preoperative RT. Median dose was 44 Gy (5-73 Gy). Surgery was performed in a mean time of 5 weeks after RT. Pathologic specimens have been reviewed by the same pathologist in order to specify the modified Astler Coller classification (MAC), and to quantify the residual tumor cell density (RTCD). RESULTS: According to the MAC, there was 9 stage 0 (5%), 10 stage A (6%), 103 stage B1-B3 (62%), and 45 stage C1-C3 (27%) tumors. Seventeen percent and 56% of the patients who received a dose > or = 44 Gy had respectively a 0-A and a B tumor, compared to 4 and 69% in those who received a dose < 44 Gy (p = 0.04). Tumor differentiation and a longer interval before surgery were significantly associated with a more frequent downstaging, and preoperative staging correlated well to the postoperative pathological findings. According to the RTCD, 62 tumors (37%) showed no or only rare foci of residual tumor cells (Group 1); 62 (37%) showed an intermediate RTCD (Group 2); and 43 (26%) a high RTCD (Group 3). No predictive factor of RTCD was statistically significant. In univariate analysis, postoperative staging was a significant prognostic factor, with corresponding 5-year overall survival rates in 0-A, B, and C stages of 92, 67, and 26% (p < 0.01). RTCD was not a prognostic factor. However, overall and disease-free survival rates for patients with complete pathologic response of 83% at 2 and 5 years suggested a better outcome in this subgroup of patients. CONCLUSION: The favorable influence of higher doses of preoperative RT on pathologic stage has been observed. Tumor differentiation, preoperative classification and time before surgery were the other predictive factors of tumor downstaging. However, there was no predictive factor of complete pathologic response. Even after preoperative RT, postoperative staging remained a prognostic factor.

Disappearance of the in situ component: a criterion predictive of metastasis in breast cancer after local relapse.

Local recurrence after conservative treatment of breast cancer is associated with a significant risk for metastasis. In order to identify criteria predictive of metastasis in this subset of women, we analyzed a series of 35 patients with local relapse among 512 consecutive patients treated with tumorectomy and radiotherapy. When relapse occurred within 2 years of initial treatment, overall 2-year survival from the time of local relapse was 39.5%. When local relapse occurred more than 2 years from initial therapy, 2-year survival was 80.5% (p < 0.001). Pathological slides of both initial and recurrent tumors were reviewed and compared. In 17 patients, local relapse and initial tumor had the same morphological features, with an in-situ component either absent or present in the same proportion. Metastasis occurred in two of these patients. In contrast, 9 of 12 patients in whom the proportion of non-invasive carcinoma had decreased at the time of local recurrence developed metastasis. Overall 2-year survival from the time of relapse was significantly better in the former group of patients (93.3% versus 52.5%, p < 0.05). We concluded that early relapses have a poor prognostic significance and that disappearance of the in-situ component or increase of the invasive component at the time of relapse is a feature predictive of tumor-related death and that more intensive therapy might benefit to this subset of women.

Squamous cell carcinoma of the base of the tongue: results of treatment in 115 cases.

Between 1976 and 1986, we treated 115 patients (mean age 53.8 years) with base of tongue carcinomas. The staging system used was the UICC TNM classification of 1979. Seventy per cent of the tumours were T3 or T4 and 42% had N2 or N3 lymph node. Locoregional treatment was irradiation alone (98/115) or surgery and post-operative radiotherapy (17/115). Sixty-seven patients received induction chemotherapy. Actuarial survival of the entire group at 3 and 5 years was 25 and 23%, respectively, and 3-year actuarial survival rates for T1, T2, T3 and T4 lesions were 42, 48, 20 and 17%, respectively. The local control rate at the primary site was 55% and 78% in the neck. Distant metastases occurred in 10% of patients and 8% had a second primary. Nodal status was the only other prognostic factor. The local control rate obtained with irradiation alone was not good. For limited T1 and T2 tumours, interstitial therapy or surgery should improve the local control rate.

Oropharynx carcinoma: irradiation alone versus induction chemotherapy plus irradiation--5 year results.

Induction chemotherapy (CT) has demonstrated overall response rates of 80% for oropharynx carcinomas, but no overall survival benefit has been reported. In order to determine the value of induction CT for such patients, we conducted a retrospective study: 121 patients were treated with CT and radiotherapy (RT) (Group 1). This group was compared with a historical group of 84 patients treated by RT alone (Group 2). The CT used was Cisplatinum associated with Bleomycin and Vincristin or Vindesin and with 5 Fluoro-uracil. An objective response to CT was observed for 41% of patients. The 5 year actuarial survival rate was 19% for Group 1 and 24% for Group 2. Patterns of failure were identical in the two groups. The only difference observed was for patients with N3 nodes (26% of 5 year survival rate in Group 1 versus 9% in Group 2) (p = 0.05). The results did not depend on the histological differentiation, the tumour site or the type of CT. We conclude that this retrospective study failed to demonstrate an advantage for induction CT in oropharynx carcinoma except for patients with N3 nodes.

Lymphadenectomy in the management of endometrial carcinoma stage I and II. Retrospective study of 155 cases.

In our institution endometrial carcinomas Stage I and II were treated with initial uterovaginal brachytherapy 60 Gy followed by modified radical hysterectomy with pelvic lymphadenectomy. We have studied the results in order to assess the value of lymphadenectomy in the treatment strategy. Between 1976 and 1986, 155 patients were treated (107 Stage I, 48 Stage II mean age 60.2 years). Twenty-six patients also received postoperative pelvic external beam irradiation on account of lymph node involvement and/or deep tumour invasion into the myometrium. Fourteen patients (9%) had lymph node involvement. External iliac lymph nodes were involved in 78.5% of these cases. Lymph node involvement rate was higher for stage II, grade 3 tumours and when there was deep tumour invasion of the myometrium. The rate of local (pelvic) treatment failure was 12% for node-negative patients and 36% for node-positive patients and the 5-year actuarial survival rates for the two groups were 83% and 41% respectively. As a consequence of our interpretation of the findings and influenced by the high complication rate which we attribute to lymphadenectomy and the information given by other prognostic indicators, we have changed to a policy of carrying out pelvic external radiotherapy for all Stage II, grade 2 or 3 cases and those with deep myometrial invasion. Lymphadenectomy is not performed in these cases. For patients with Stage I grade 1 tumours without deep tumour invasion only external iliac node sampling is performed. If this shows tumour, external irradiation is given in addition to vaginal vault brachytherapy.

Abdomino pelvic irradiation after second-look laparotomy for stage III ovarian carcinoma.

OBJECTIVE: The purpose of this retrospective analysis of 34 patients with stage III ovarian carcinoma was to review results and morbidity of whole abdominal irradiation after surgery and chemotherapy. METHODS AND MATERIALS: All of the 34 patients had reached a complete clinical remission after first cytoreductive surgery and chemotherapy. After second-look laparotomy each patient underwent whole abdominal irradiation. Except for two patients with chronic myelosuppression, the dose administered was of 22.5 Gy to the abdominal cavity with a boost of 22.5 Gy added to the pelvis. RESULTS: Three and 5-year overall survival rates were 62% and 43%, respectively. Three and 5-year disease-free survival rates were 53% and 38%. Twenty-three patients (68%) developed local relapse or local disease progression. Metastasis occurred in five cases and were always associated with an abdominal cavity recurrence. Residual disease after first cytoreductive surgery appeared as a prognostic factor in univariate analysis. Patients with unresected residuum had a 5-year survival probability of 35% versus 83% for patients without residual disease. We observed 12% grade-3 intestinal toxicities and one fatal case of radiation enteritis. CONCLUSION: Despite its curative potential, the long term benefit of whole abdominal irradiation in the multimodality treatment of advanced ovarian carcinoma must be evaluated in well designed controlled trials.