Callosotomy for intractable epilepsy: overall outcome

The effectiveness of callosotomy to the control of medically intractable epilepsy is still discussed fifty years after the first reported cases. Nevertheless patient selection, type of seizures and epileptic syndromes are now better determined. Atonic and tonic astatic seizures characterized both by clinical and electroencephalographical specific patterns, are the most responsive. A favorable outcome, from > 50% reduction in seizure frequency to a complete cessation, is obtained from 60 to 80% of the patients. For tonic-clonic seizures, favorable outcome fluctuates from 40% to 80% principally according to the extension of the section. Other types of seizures are not indicated for callosotomy even though some improvement may be observed. Symptomatic secondary generalized epilepsy with predominent unilateral lesion and epileptic focus on bifrontal lobe epilepsy are the most suitable indication. True generalized epilepsies are associated with a less favorable outcome. Indeed, axial spasms, the most frequent type of drop attacks in the Lennox-Gastaut syndrome, probably do not have a cortical origin. Quality of life and social adjustment are assessed from a cohort of 20 cases of anterior two-third callosotomy. Actual benefits are in close connection with both seizure relief and age at operation. To obtain a gain in social independence not only seizure control has to be better but also surgery must be performed sooner.

Complications following definitive irradiation for cancers of the oral cavity and the oropharynx (in a series of 1134 patients)

PURPOSE

To study the rate and severity of complications in a series of 1134 patients treated by definitive irradiation for tumors of the oral cavity (772 cases) or the oropharynx (361 cases).

METHODS AND MATERIALS

Patients were staged as 29.5% T1, 42% T2, 26% T3, 2.5% T4-Tx, and 74.5% N0 tumors. We treated 364 patients with brachytherapy only (192Ir) for the primary lesion. External irradiation and brachytherapy were combined for 770 patients.

RESULTS

The results included local control and survival. Out of 1134 patients, 330 had 376 complications. Grade 1 complications occurred in 20% of the patients, Grade 2 in 9%; Grade 3 in 4%; and Grade 4 in 0.2%. Of the Grade 1 complications, 78% were soft tissue and only 24% were bone complications. For the more severe grades (2, 3, and 4), there were 56 soft tissue complications and 90 bone complications out of 1340 patients. The statistical analysis included tumor-related factors and treatment-related factors. For the first two factors, only tumor location was significant. The treatment-related factors significant for complications were studied in univariate and multivariate study. This multivariate study confirmed that for soft tissue complications dose rate and volume treated were important (p < 0.001). It also confirmed that for bone complications, total dose > 80 Gy, dose rate > 0.7 Gy/h, and the absence of leaded protection of the mandible were all important factors.

CONCLUSION

This statistical study should allow future reduction of severe complications (Grades 2, 3, 4), if treatment factors inducing them can be taken into account. This is not always possible for very large tumors.

Evaluation of Taxol in head and neck squamous carcinoma multicellular tumor spheroids

Taxol cytotoxicity was evaluated in human head and neck squamous carcinoma cell lines growing as multicellular tumor spheroids (MTS) and compared with monolayered culture using conventional clonogenic assays. End points were respectively the concentration inhibiting 50% of the cellular growth (IC50) in clonogenic assays and the concentration required to induce a 50% decrease in the MTS volume (ID50) or number in the overall spheroid population (SCC50). A significant difference was observed when the cells were exposed for 10 days to Taxol as a consequence of the different growth kinetics of the spheroids. After 16 day exposure of spheroids to Taxol, no difference remained between ID50 and IC50. In addition, a significant correlation was found between individual spheroid sensitivity to Taxol (ID50) and the spheroid population sensitivity (SCC50). Both parameters (ID50 and SCC50) defined in cell models appear useful for the evaluation of chemosensitivity of three-dimensional structures known to be closer to in vivo tumor models.

Ductal carcinoma in situ of the male breast. Analysis of 31 cases

From 1970 to 1992, 31 pure ductal carcinoma in situ (DCIS) of the male breast treated in 19 French Regional Cancer Centres were reviewed. They represent 5% of all breast cancers treated in men in the same period. The median age was 58 years, but 6 patients were younger than 40 years. TNM classification (UICC, 1978) showed 12 T0 (discovered only by bloody nipple discharge), 10 T1, 5 T2 and four unclassified tumours (Tx). 11 patients (35.5%) had clinical gynecomastia, and three (10%) had a family history of breast cancer. 6 patients underwent lumpectomy, and 25 mastectomy. Axillary dissection was performed in 19 cases. 6 cases received postoperative irradiation. 15 out of 31 lesions were of the papillary subtype, pure or associated with a cribriform component. The size of the 12 measured lesions varied from 3 to 45 mm. All lymph nodes sampled were negative. With a median follow-up of 83 months, 4 patients (13%) presented a local relapse (LR), respectively, at 12, 27, 36 and 55 months. 3 of these patients had been initially treated by lumpectomy. In one case LR was still in situ, but already infiltrating in the 3 others. Radical salvage surgery was performed in 3 cases, but one patient developed metastases and died 30 months later. The last patient was treated by multiple local excisions and tamoxifen. One 43-year-old patient developed a contralateral DCIS and three others developed a metachronous cancer. The aetiology and risk factors of male breast cancer remain unknown. Gynecomastia, which implies an imbalance between androgen and oestrogen, may be a predisposing factor. As in women, DCIS in the male breast has a good prognosis. Total mastectomy without axillary dissection is the basic treatment. Frequently, the first symptom is a bloody nipple discharge. The age of occurrence is younger than for infiltrating carcinoma, suggesting that DCIS is the first step in the development of breast cancer.

In vitro evaluation of Taxol combined with radiations in human squamous cell carcinoma spheroids

The effect of Taxol on the radiation sensitivity of human squamous carcinoma of the head and neck region was determined in vitro, using clonogenic assays and multicellular tumor spheroids (MTS). Radiosensitivity parameters were determined by alpha and beta for clonogenic assays, and by the residual/control volume ratios at 2 Gy (RSV2) and the dose inducing 50% decrease in MTS number (SCD50) for spheroids. In HTB43 and CAL27 colonies, the combination was antagonist. In spheroids, Taxol induced a decrease of RSV2 and SCD50 in HTB43 and CAL27 MTS and their combinations with radiation were synergistic and additive, respectively. Therefore, the different results obtained by clonogenic assays and MTS may suggest higher drug incorporation through the multiple cell layers of the spheroids than in monolayers.

Role of interstitial brachytherapy in oral and oropharyngeal carcinoma: reflection of a series of 1344 patients treated at the time of initial presentation

Our study focuses on a series of 1344 cases of carcinoma of the oral cavity and oropharynx treated between 1973 and 1992. Brachytherapy was always performed with iridium 192, either alone or in combination with external-beam irradiation or with surgery for the treatment of the primary tumor. For the oral cavity, we studied 565 cases of mobile tongue. The local control and overall survival rates, respectively, at 5 years are as follows: for T1, 92% and 70%; for T2, 62% and 42%; and for T3, 50% and 29%. For the subgroup T1T2NO, there was a better prognosis for treatment by brachytherapy of the primary lesion alone (p < 0.0001). Two hundred seven cases of floor-of-mouth carcinoma have been reported. The T3T4 patients were not considered surgical candidates. The local control and overall survival rates, respectively, at 5 years are as follows: for T1, 97% and 71%; for T2 72% and 42%; and for T3, 51% and 35%. Ninety-seven patients were treated by postoperative brachytherapy. These were patients for whom the margins after surgery were positive or narrow. A technique termed the modified bridge is described for lesions located in the mandible. Carcinomas of the buccal mucosa are rare in our country; only 42 cases were treated in this comparison of two techniques, and the overall survival rate was 48%. Epidermoid carcinomas of the oropharynx have nearly always been treated by a combination of external-beam irradiation and brachytherapy because of the bilateral node risk. Seventy-two patients with epidermoid cancers of the base of the tongue had an overall survival rate of 44%. The tonsil, soft palate, and pillars benefited from the use of the loop technique of brachytherapy combined with external-beam irradiation. Three hundred sixty-one patients were treated. Among these patients were two groups with different prognoses. Patients with tonsil, soft palate, and posterior pillar carcinomas had a local control rate of 84% and an overall survival rate of 57%. Conversely, the anterior pillar and the pharyngoglossal sulcus have a local control rate of only 65% and an overall survival rate of 38%. Statistical analysis revealed the prognostic factors for local control. The complications were classified into four grades: minor (20%), moderate (9%), major (4%), or inducing death (0.2%). The bone complications of grade 2 or 3 are more frequent for the floor of the mouth than for other locations.

Role of Interstitial Brachytherapy in Oral and Oropharyngeal Carcinoma: Reflection of a Series of 1344 Patients Treated at the Time of Initial Presentation

Our study focuses on a series of 1344 cases of carcinoma of the oral cavity and oropharynx treated between 1973 and 1992. Brachytherapy was always performed with iridium 192, either alone or in combination with external-beam irradiation or with surgery for the treatment of the primary tumor. For the oral cavity, we studied 565 cases of mobile tongue. The local control and overall survival rates, respectively, at 5 years are as follows: for T1, 92% and 70%; for T2, 62% and 42%; and for T3, 50% and 29%. For the subgroup T1T2N0, there was a better prognosis for treatment by brachytherapy of the primary lesion alone ( p < 0.0001). Two hundred seven cases of floor-of-mouth carcinoma have been reported. The T3T4 patients were not considered surgical candidates. The local control and overall survival rates, respectively, at 5 years are as follows: for T1, 97% and 71%; for T2, 72% and 42%; and for T3, 51% and 35%. Ninety-seven patients were treated by postoperative brachytherapy. These were patients for whom the margins after surgery were positive or narrow. A technique termed the modified bridge is described for lesions located in the mandible. Carcinomas of the buccal mucosa are rare in our country; only 42 cases were treated in this comparison of two techniques, and the overall survival rate was 48%. Epidermoid carcinomas of the oropharynx have nearly always been treated by a combination of external-beam irradiation and brachytherapy because of the bilateral node risk. Seventy-two patients with epidermoid cancers of the base of the tongue had an overall survival rate of 44%. The tonsil, soft palate, and pillars benefited from the use of the loop technique of brachytherapy combined with external-beam irradiation. Three hundred sixty-one patients were treated. Among these patients were two groups with different prognoses. Patients with tonsil, soft palate, and posterior pillar carcinomas had a local control rate of 84% and an overall survival rate of 57%. Conversely, the anterior pillar and the pharyngoglossal sulcus have a local control rate of only 65% and an overall survival rate of 38%. Statistical analysis revealed the prognostic factors for local control. The complications were classified into four grades: minor (20%), moderate (9%), major (4%), or inducing death (0.2%). The bone complications of grade 2 or 3 are more frequent for the floor of the mouth than for other locations.

[Diagnostic and therapeutic characteristics of breast cancer in elderly women. Groupe Sein du Centre Alexis Vautrin]

Because of its high incidence and the high number of deaths induced, breast cancers in elderly women is a major health problem. The diagnosis is often clinical and the tumors are often at advanced stage with many initial metastases due to some neglect. Breast cancer in elderly women has no specific radiological form and is more often infiltrating ductal carcinoma of SBR grade I. Hormonal receptors are generally higher in elderly than in young women. Surgery of breast cancers with equal anesthetic risks factors does not induce more complications in elderly women than in the general population. In 12% of cases, an associated pathology influences the decision (degradation of the respiratory or cardiovascular function or reduction of the renal function). Between 70 and 80 years, provided that life expectancy is compatible with radiotherapy, corollary to conservative treatments in the present state of our knowledge for tumors under 3 to 4 cm, there is an alternative between radiosurgical conservative treatment and modified mastectomy associated with axillary dissection. In case of bulky tumors (> 3 to 4 cm) and failure of the hormonal treatment or impossibility to perform a complementary radiotherapy treatment (for instance, senile dementia), of axillary node involvement, a fortiori if the tumor has no hormonal receptors, the modified mastectomy with axillary dissection remains the therapeutic standard. In case of bulky tumor, the hormonal status can be used to induce the patient to accept an operation and, if necessary, to perform a conservative surgery. However, despite hormonosensitivity of breast cancer, a tumoral progression after a mean duration of hormonosensitivity of 25 months is to be expected in 93% of the cases, included 25% in whom a complete response to hormonotherapy was observed. A fractionated irradiation delivering 2 Gy per fraction and 5 fractions per week with a total number of sessions of 25 gives better esthetical results. This optimal treatment lasts 5 weeks and the patients often get tired since they are old and their radiotherapy centre is far from their house. Therefore hypofractionated treatment (once a week) should be proposed. The adjuvant medical treatment of reference for menopausal women is hormonotherapy by tamoxifen. Breast cancer in elderly women reduces life expectancy at 5 years by 50%; the theoretical therapeutic indications are the same as for young women, but their application is adapted to the patient. It would be dangerous and illusive to undertreat such a disease when the life expectancy is longer than 3 years.

[Recent progress in radiotherapy]

Radiation therapy has considerably evolved in 1 century. After the revolution due to cobalt in the beginning of the sixties, we are now entering the 2nd revolution in three fields in external radiotherapy.

METHODOLOGY

the development of quality assurance programmes gives the guarantee that the treatment is done as it is prescribed. Technology: recent developments allow conformal radiation therapy which permits to increase the dose without increasing side effects. Biology: the implementation of predictive assays will permit to choose the best modality of treatment for each patient. In brachytherapy, the use of high dose rate radioactive sources increases indications in locations not yet accessible. Pulse dose rate brachytherapy increases radio-protection and will make optimization possible in complex volumes. In the future, indications of curative radiotherapy will probably increase in regard to earlier diagnosis of many cancers and to increase of efficacy of general treatments on metastatic disease.

Association of docetaxel/paclitaxel with irradiation in ovarian carcinoma cell lines in bidimensional (sulforhodamine B assay) and tridimensional (spheroids) cultures

The association of taxoid derivatives (paclitaxel and docetaxel) with irradiation was evaluated in ovarian carcinoma cell lines (A2780 and CAVEOC-2) using the multicellular tumor spheroids (MTS) tridimensional model and compared to the conventional bidimensional model. The radiosensitivity parameters were the surviving fraction at 2 Gy, and alpha calculated using the linear-quadratic model for monolayer culture, the residual/control volume ratios at 2 Gy (RSV2) and doses inducing 50% decrease in MTS number (SCD50) calculated for spheroids. In A2780 monolayer culture, the combination was synergistic for paclitaxel and additive for docetaxel. In spheroids, both compounds induced a decrease in RSV2 and SCD50 in the two cell lines, and their combination with radiation was additive. Therefore, the radiosensitizing effect of taxoid derivatives was not constant in ovarian cell lines. The different results achieved in monolayer culture and in spheroids may suggest higher drug incorporation and fixation through the multiple cell layers of the spheroids than in monolayers.

[Precapillary pulmonary arterial hypertension disclosing systemic lupus erythematosus]

Precapillary pulmonary hypertension was diagnosed in a 29 year old woman who became progressively more breathless (NYHA Class III) after her pregnancy, two years previously: systolic pulmonary artery pressure was 120 mmHg with an arterio-capillary pressure gradient of 30 mmHg. She had anti-nuclear autoantibodies detectable at 1/1000 and anti-DNA autoantibodies at 1/800 without any other manifestation of lupus. Treatment with prednisone (2 mg/kg/day) resulted in regression of her dyspnoea with a decrease of systolic pulmonary artery pressure to 65 mmHg, and of the arterio-capillary gradient to 15 mmHg; the lupus serology became negative with a clinical follow-up of 37 months. This observation shows that systemic lupus erythematosus may present with precapillary pulmonary hypertension, the conventional treatment of which may be successfully completed by steroid therapy.

Sensitivity to taxoid derivatives of a newly established human endometrioid ovarian adenocarcinoma radioresistant cell line

An endometrioid ovarian adenocarcinoma cell line CAVEOC-2 was characterized. Maintained in monolayered culture, CAVEOC-2 cells exhibited a 33-hr doubling time. When xenografted into nude mice, these cells produced fast growing tumors. Colony-forming efficiency in agar was 50%. DNA index was 1.5 and cytogenetic analysis showed a triploid karyotype. CAVEOC-2 cells did not express mdr-1 gene and were chemosensitive to doxorubicin (IC50 = 1.82 +/- 0.76 mumol/l), paclitaxel (IC50 = 3.33 +/- 0.26 nmol/l) and docetaxel (IC50 = 0.68 +/- 0.28 nmol/l), while they showed an intermediate sensitivity to cisplatin (IC50 = 9.40 +/- 1.02 mumol/l). CAVEOC-2 cells seemed highly radioresistant (SF2 = 0.81, alpha = 0.02 Gy-1, beta = 0.025 Gy2, and MID = 4.31 Gy). Activities of glutathione S transferase and gamma-glutamyl transpeptidase were respectively 23.5- and 3.4- fold higher than those of sensitive A2780 cell line. These characteristics make the CAVEOC-2 cells a suitable model for the study of human endometrioid ovarian adenocarcinoma.

Lymphoplasmacyte-rich meningioma in a child. Case report

A rare case of lymphoplasmacyte-rich meningioma observed in a young girl is reported. The first clinical manifestations of the disease were seizures. Neuroradiological images favored the existence of a meningioma. Abnormalities in the patient's blood chemistry, principally including hypergammaglobulinemia and inflammatory syndrome, were associated with the disease. The tumor was histologically confirmed as meningioma with massive infiltrates of type B lymphocytes. The pathophysiology of the conspicuous lymphoplasmacyte infiltrates, responsible for peripheral blood abnormalities, has remained poorly understood. Alternative diagnostic hypotheses of masses that mimic this type of meningioma are discussed.

Male breast cancer: results of the treatments and prognostic factors in 397 cases

From 1960 to 1986, 397 cases of non-metastatic male breast cancer (MBC) treated in 14 French regional cancer centres were reviewed. The median age was 64 years (range 25-93). TNM classification (UICC, 1978) showed seven T0, 79 T1, 162 T2, 31 T3, 74 T4 and 44 unclassified tumours (Tx). Clinical positive lymph nodes were found in 31% of the patients. 24 patients received radiotherapy only, and 373 underwent surgery, 247 of these with postoperative irradiation. Adjuvant chemotherapy and hormonal therapy were used in 71 and 68 patients, respectively. There were 382 infiltrating carcinomas and 15 pure ductal carcinoma in situ. Lymph node involvement was found in 56% of infiltrating carcinoma. The oestrogen (ER) and progesterone (PgR) receptors were positive in 79% and 77%, respectively, of examined cases. Isolated local and regional recurrence were observed in 8.8% and 4.5% of cases, respectively and 40% of patients developed metastases. The crude survival rates by Kaplan-Meier method were 65% and 38% at 5 and 10 years, respectively, and the disease-specific survival rates (without death due to intercurrent disease or second cancer) was 74% at 5 years and 51% at 10 years. The disease-specific survival rate for pN- and pN+ groups were 77% and 39% at 10 years. The prognostic factors were clinical size (T) and histological axillary status (pN-/pN+). The relative risk of death for pN- was 1.0, 2.0 and 3.2 in the T0-T1, T2 and T3-T4 groups, respectively. For pN+, these relative risks increased 1.9, 3.9 and 6.0 in the same groups. The optimal treatment include modified radical mastectomy and irradiation for cases with risk factors of local relapse (nodal invasion, large tumour with cutaneous or muscular involvement). Locoregional failure had unfavourable prognosis. First-line adjuvant treatment seems to be tamoxifen, due to the very high rate of positive hormonal receptors and the old age of the patients, which contraindicate chemotherapy in many cases. The prognosis of patients with breast cancer is the same in male and female patients when disease-specific survival rate, tumour size and axillary involvement are compared.

[Statistical study of a series of 672 cases of carcinoma of the uterine cervix. Results and complications according to age and modalities of treatment]

The study bears on 672 infiltrating carcinomas of the cervix treated from 1977 until the end of 1991, by a radiosurgical combination (311 patients) or by exclusive irradiation (361 patients). The radiosurgical series includes mostly stages IB and II and patients under 50 years because of the therapeutic protocol. Most of the patients aged over 50 years and all stages III were treated by exclusive irradiation. External beam irradiation was most often performed in 4 fields by linear accelerator of 12 and 25 MeV. Uterovaginal brachytherapy used the technique of molds. In 55 cases, a complementary interstitial brachytherapy was applied on residual node. A computer dosimetry was made for each patient with calculation of the doses delivered to organs at risk and to node areas (points of calculation ICRU n degrees 38). The results at 5 years are as follows for the total series: locoregional control (LRC) 79%, specific survival (SS) 73%, overall survival 70%. For stage I, the LRC of the radiosurgical series is 92%, that of the series of exclusive irradiation 87% (no significant difference, neither for SS if we consider the tumoral size); For stage II, the LRC is 70% in the radiosurgical series and 79% in the series of exclusive irradiation. There is no difference if proximal stage II is compared. Conversely, for distal stage II, the difference is very significant in favour of exclusive irradiation (LRC 31%/77%, SS 26%/70%, p < 0.006). If we consider the results according to age, the difference for distal stage II comes mostly from patients under 50 years and especially those aged 40 years or under. For stage III, the LRC is 61% for patients over 50 years and 34% for those aged 50 years or under (p = 0.006). As the nodes, the results of surgical pieces and lymphadenectomy are studied. The patients under 40 years in stages II and III present more metastases than others (p = 0.003). Among the therapeutic factors, the dose rate and the treatment duration were particularly studied. A detailed study of the complications is made for the radiosurgical series as for the series of exclusive irradiation according to the French Italian glossary of complications as well as a study of the factors inducing them.

Radiotherapy and chemotherapy for invasive thymomas: a multicentric retrospective review of 90 cases. The FNCLCC trialists. Fédération Nationale des Centres de Lutte Contre le Cancer

PURPOSE

Thymoma is a rare disease. The treatment of patients with invasive thymoma remains controversial. The prognosis of such patients is poor, even with the use of postoperative radiation therapy and chemotherapy. We retrospectively reviewed the outcome and prognostic factors in a series of 90 patients presenting with an invasive thymoma treated by partial resection or biopsy and radiation therapy.

METHODS AND MATERIALS

From 1979-1990, 163 patients with the diagnosis of lymphoepithelial thymoma were treated in 10 French cancer centers. Patients were staged using the postoperative "GETT" classification derived from that of Masaoka. Ninety patients who presented with an invasive thymoma, 58 Stage III (21 IIIA: partial resection and 37 IIIB: biopsy) and 32 Stage IVA (intrathoracic thymoma spread), are the subject of this report. Treatment combined surgery and radiation therapy (+/- chemotherapy), with curative intent. Surgery consisted of partial resection in 31 patients (21 Stage III), and biopsy in 55 patients (37 Stage III). The median radiation dose to the tumor was 50 Gy (30-70 Gy). Supraclavicular radiation was performed in 59 patients (median dose 40 Gy). Chemotherapy, combined with radiation in 59 patients, consisted of multidrug regimens, mainly platinum based.

RESULTS

The median follow-up is 105 months (20-165 months). The 5- and 10-year overall survival rates are 51 and 39%, respectively. There is a great impact of the extent of surgery on survival: the 5- and 10-year survival rates were 64% and 43%, respectively, after partial resection, compared to 39% and 31% after biopsy (p < 0.02). Local control at 8.5 years was obtained in 59 of 90 patients (66%): 40 Stage III, 19 Stage IVA. There is a significant relationship between the extent of surgery and the local control (16% of relapse after partial resection vs. 45% after biopsy, p < 0.05). Seven patients developed significant (grades 3-4 WHO grading system) treatment-induced side effects. Stage, histologic type, and chemotherapy were not prognostic factors.

CONCLUSION

In this large multicentric retrospective study of invasive thymomas (Stage III-IVA) treated by surgery and radiation, results show the importance of loco-regional treatments, such as surgery and radiation therapy. There is also a great impact of radiation on local control. However, the rate of local recurrence (34%) justifies recommending a higher dose of radiation (> 50 Gy) than doses used in this study, for incompletely resected patients. The role of chemotherapy needs to be further assessed.

Epidermoid carcinomas of the floor of mouth treated by exclusive irradiation: statistical study of a series of 207 cases

PURPOSE

Our aim was to study the results and the complications of this series of 207 patients treated from 1976 to 1992 and to compare them with the results of the literature.

MATERIAL AND METHODS

The treatment consisted of a combination of external beam irradiation (EBI) (to the tumor and the node areas) and complementary brachytherapy to the primary tumor in 105 cases. In 102 cases, brachytherapy only was delivered to the tumor with or without neck dissection of the node areas. The brachytherapy was performed mostly with the hairpin technique in the beginning (in 61 cases) and subsequently the plastic tube technique with iridium wires. The dosimetry followed the Paris system rules. There were 41% T1, 48% T2, 8% T3, 2% T4 and 1% Tx with 83% N0, 12% N1, 3% N2, 2% N3. Ninety-one percent of patients were male and 9% were female.

RESULTS

The local control at 5 years is 97, 72 and 51%, respectively, for T1, T2, T3. The specific survival (without the patients dead of intercurrent disease or second cancer) was 88, 47 and 36%, and the overall survival at 5 years was 71, 42 and 35%. Of note, approximately one third of patients died of intercurrent disease or second cancers (70 patients = 34%). Significant factors that can influence the results are: for local control, the size of the lesion T1/T2/T3 (p < 0.0001); for the locoregional control, the absence of node involvement. The following factors are not significant: age and sex (age significant for survival). The significant treatment factors are the safety margin (p < 0.0003), brachytherapy only on T for T2N0 (p = 0.01). A total duration of treatment of less than 50 days is also significant. The spacing and the total dose (higher dose for large tumors) were not found to be significant. The complications were classified into four grades: grade 1, 17% (median healing, 2 months for soft tissue complications and 5 months for bone complications); grade 2, 12%; grade 3, 6% (frequently requiring surgical resection); grade 4, 0.5% (death, one case). In this series, for the complications, the dose rate, the spacing and the total dose were found not to be significant.

CONCLUSION

Carcinomas of the floor of mouth treated by exclusive irradiation have a rather good prognosis and the number of grade 2 and 3 complications remains acceptable. Exclusive brachytherapy is preferable to the combination of EBI plus brachytherapy for T1T2N0.

Indications, techniques and results of postoperative brachytherapy in cancer of the oral cavity

PURPOSE/OBJECTIVE

We tried to reduce the number of local recurrences after surgery and external beam irradiation (EBI) in carcinoma of the oral cavity, when margins were positive or close.

MATERIAL AND METHODS

From 1980 to 1992, we treated 97 cases of carcinomas of the oral cavity by postoperative brachytherapy. Surgery was combined with EBI+brachytherapy in 51 cases and with brachytherapy alone in 46 cases. We treated 29 T1, 34 T2, 30 T3T4 and four Tx (73% were N0 at first examination and 23% had positive nodes). The type of surgery is analysed. Brachytherapy was performed in one or two planes along the surgical scar. If the mandibular rim was resected, especially when the tongue or the remaining floor were sutured to the internal face of the inferior lip or to the buccal mucosa, the bridge technique was used. To decrease the dose to the inferior part of the mandible, the bridge was modified thanks to experimental dosimetry.

RESULTS

At 5 years, the local control (LC) is 89%, the locoregional control (LRC) 82%, the specific survival (SS) 74% and the overall survival (OS) 67%.

COMPLICATIONS

We noted 19% of grade 1 (minor), 12% of grade 2 (moderate) and 6% of grade 3 (major) complications.

CONCLUSION

Compared with the results of the literature, we think that postoperative brachytherapy can improve classical radiosurgical results in selected cases with a risk of local recurrence.

Comparison of sulforhodamine B, tetrazolium and clonogenic assays for in vitro radiosensitivity testing in human ovarian cell lines

The radiation sensitivity of six human ovarian tumor cell lines was evaluated using sulforhodamine B (SRB), tetrazolium (MTT) and clonogenic assays. Radiobiological parameters calculated from a linear quadratic model (SF2, alpha, beta) as well as from a single-hit multitarget model (D(o), Dq, n) and from the area under the dose-response curve (mean inactivation dose; MID) were compared. If the values deduced from MTT experiments were statistically comparable to those obtained from clonogenic assays, significant differences were observed between SRB and the two other assays that concerned the results achieved with the highest radiation doses tested (6-8 Gy), yielding a surviving fraction of approximately 20%. In addition, the intra- and inter-experimental variation of SRB dramatically increased within this range of radiation doses. However, up to 6 Gy, the SRB assay proved to be statistically comparable to MTT and clonogenic assays, and allowed the calculation of SF2, alpha and MID radiobiological parameters.

Radiosensitivity of multicellular tumour spheroids obtained from human ovarian cancers

The radioresponsiveness of immunologically characterised (KL1, antivimentin and OC125) human ovarian carcinoma cells, obtained from effusions or solid tumours, was assayed in vitro using the multicellular tumour spheroids (MTS) three-dimensional model. Great interspecimen variabilities were observed in MTS doubling time (1.0-8.5 days), as well as in the doses inducing a 50% decrease in the MTS individual volume (ID50) (0.56-9.15 Gy), or in the overall population MTS number (SCD50) (1.9-15.7 Gy) and the residual/initial MTS individual volume ratio after 2 Gy irradiation (RSV2) (10-88%). The doubling time, DNA-ploidy and S-phase fraction did not correlate with the ID50. Significant correlations were found between the new parameters defined (RSV2 and ID50) and the SCD50, a well-accepted local control parameter. These parameters demonstrated their usefulness for studying the radiosensitivity of MTS prepared from human ovarian tumour biopsies.

Thymoma: results of a multicentric retrospective series of 149 non-metastatic irradiated patients and review of the literature. FNCLCC trialists. Fédération Nationale des Centres de Lutte Contre le Cancer

Between 1979 and 1990, 149 patients with non-metastatic thymomas were treated in ten French cancer centers. Patients were staged according to the 'GETT' classification, derived from that of Masaoka. There were 13 stage I patients, 46 stage II, 58 stage III and 32 stage IVA. Gross total resections were performed in 63 cases, subtotal resections in 31 cases and in 55 cases a biopsy alone was performed. All patients received radiotherapy and 74 were given post-operative chemotherapy. Median follow-up was 7.7 years. Local control was achieved in 117 cases (78.5%) and was influenced by the stage of the disease (p < 0.01) and the extent of surgery (p < 0.01). Twenty-six patients developed metastatis after a median period of 9 months. Five- and ten-year disease-free survival rates were 59.5% (51-67%) and 49.5% (39-60%), respectively, and were influenced by the stage of the disease (p < 0.01), the extent of surgery (p < 0.001) and a mediastinal compression on presentation (p = 5 x 10(-6)). Four factors could predict a worse overall survival in the multivariate analysis: mediastinal compression on presentation (p < 0.001), absence of chemotherapy (p < 0.001), biopsy alone (p = 0.003), and young age (p = 0.013). A worse DFS was predicted by mediastinal compression on presentation (p < 0.001), absence of chemotherapy (p < 0.001), young age (p = 0.006), and stages III-IVA (p = 0.04). Future therapeutic strategies are discussed and the literature is reviewed.

Surgical treatment of an early epileptic encephalopathy with suppression-bursts and focal cortical dysplasia

A case of early epileptic encephalopathy (EIEE) with suppression-bursts or Ohtahara's syndrome, associated with focal cortical dysplasia is reported. Infantile spasms and brief tonic unilateral seizures began on the fifth day of life. Interictal EEG demonstrated an asymmetrical "suppression-burst" pattern with no wake or sleep cycling. Seizures were refractory to all antiepileptic drug (AED) and steroid therapy. Magnetic resonance imaging (MRI) showed right frontotemporal cortical thickening. After three weeks of an ineffective medical treatment a preoperative evaluation with single photon emission computed tomography (SPECT) and electrocorticography (ECoG) was performed to characterize epileptogenic focus. Surgical resection of the precentral area was performed at age 1 month. Neuropathologic examinations confirmed diagnosis of focal cortical dysplasia by identifying cytoarchitectural disarray and ectopic neurons located deep in subcortical white matter. During follow-up, 1-year postoperative the child had a single febrile seizure. Neurologic examination showed minor developmental delay and slight left-sided weakness.

Glial and neuronoglial malformative lesions associated with medically intractable epilepsy

In a large series of 116 cortical resections for treatment of medically intractable epilepsy, 10 glial hamartomas and 11 neuronoglial malformative lesions were found. Glial hamartomas were astrocytic in 3 cases, oligodendrocytic in 6 and mixed oligoastrocytic in 1. Neuronoglial lesions corresponded to "focal cortical dysplasia" in 6 patients and to "microdysgenesis" in 5 others. This study focuses on the various neuropathological presentations of these malformative epileptogenic lesions, and on correlations with neuro-imaging data.

[Diffuse neonatal hemangiomatosis. A case with tetralogy of Fallot]

In neonatal disseminated hemangiomatosis, multiple immature capillary hemangiomas are widely distributed in the skin, mucous membranes, and internal organs including the liver, lungs, and larynx. In patients with life-threatening visceral involvement, corticosteroids or interferon may be required. A case in a female infant with tetralogy of Fallot is reported.

[Role of ultrasonographic tests in the diagnosis of moderate to severe pulmonary embolism]

Between November 1991 and June 1992, 50 patients suspected of pulmonary embolism (SP > 20%) underwent Doppler echocardiography, venous Doppler ultrasonography and pulmonary angiography. Pulmonary embolism was confirmed by pulmonary angiography in all patients but 3 (2 pts: mean pulmonary pressure > 50 mmHg and 1 pt: mobile thrombus between the infundibulum and the main pulmonary artery). Two groups were identified on the basis of Miller's index: Group 1: "non-massive" pulmonary embolism, Miller < 60% (n = 18); Group 2: "massive" pulmonary embolism, Miller > or = 60% (n = 29). The patient with thrombus in the main pulmonary artery and the two with high pulmonary pressures were included in Group 2. Venous Doppler ultrasonography was performed in 96% (n = 48) of patients, including 90% within the first 24 hours. No distinction could be drawn between the two groups on the basis of venous Doppler ultrasonography findings. A majority of patients had thrombosis of main collecting vessels (Group 1 = 75%, Group 2 = 78%) and 10% of patients had no venous thrombosis of the lower limbs. Doppler echocardiography was performed in all patients, including 94% (n = 47) within the first 24 hours. Dilatation of the left ventricle as well as analysis of septal contraction was evaluable in all patients except one of Group 2, because of poor technical quality and of artificial pacing. A RV/LV ratio > 0.60 was found in 97% (30/31) of patients of Group 2 as compared with 39% (7/18) in Group 1.(ABSTRACT TRUNCATED AT 250 WORDS)

Occurrence of polyglucosan bodies in temporal lobe epilepsy

Massive occurrence of polyglucosan bodies (PBs) was found within the surgically removed temporal lobe of a 34 year old woman with complex partial seizures. This peculiar feature is very unusual in neuropathological examinations of epileptogenic foci. This patient could not be included in any of the classic diseases in which PBs are found. She exhibited a localised form of glycogen storage disease.

Role of pilA, an essential regulatory gene of Neisseria gonorrhoeae, in the stress response

Sequence analysis has shown that PilA, a transcriptional regulator of pilin gene expression in Neisseria gonorrhoeae, has extensive homology with the 54-kDa protein of the signal recognition particle of eukaryotes and its receptor, as well as with two proteins of Escherichia coli, FtsY and Ffh, which have been proposed to be a part of a signal recognition particle-like apparatus. We tested the putative role of PilA in protein export in N. gonorrhoeae and did not find any effect. However, we did observe induction of a heat shock response and a previously described slow-growth phenotype when PilA function was impaired. We also examined the interference of pilA expression in E. coli with the function of the products of ftsY and ffh and observed an accumulation of pre-beta-lactamase. We argue against a direct role for PilA in protein export in gonococci and propose instead that PilA is involved in the modulation of cell growth rate in response to different environmental conditions.

PuIO, a component of the pullulanase secretion pathway of Klebsiella oxytoca, correctly and efficiently processes gonococcal type IV prepilin in Escherichia coli

The PulO protein required for extracellular secretion of pullulanase by Klebsiella oxytoca is known to be highly homologous to two type IV prepilin peptidases, namely XcpA(PilD) (Pseudomonas aeruginosa) and TcpJ (Vibrio cholerae). The predicted prepilin peptidase activity of PulO was confirmed by showing that it could correctly process the product of the cloned pilE.1 type IV pilin structural gene from Neisseria gonorrhoeae in Escherichia coli. The P. aeruginosa prepilin peptidase and another putative prepilin peptidase, ComC from Bacillus subtilis, also processed prePilE. Subcellular fractionation showed that the pilE gene product that had been processed by PulO remained associated with the cytoplasmic membrane, as did the unprocessed precursor. PulO was also shown to process three of the four prePilE-PhoA hybrids tested. Southern hybridization experiments suggest that a pulO homologue is present in the N. gonorrhoeae chromosome.

Determination of estrogen and progesterone receptors in endometrial adenocarcinomas. Comparison between dextran-coated charcoal and immunoenzymatic methods on curettage biopsies

Estrogen receptors (ER) and progesterone receptors (PR) were determined on curettages from women with endometrial adenocarcinoma. The results obtained with the enzyme immunoassay (EIA) and the dextran-coated charcoal (DCC) assay were compared. A highly significant correlation was obtained between these methods for the ER measurement (Rs = 0.91). For PR determination, the Rs value between EIA and DCC assay was 0.57 and the mean value of PR-DCC is significantly higher than the mean value of PR-EIA. These results suggest that EIA is a suitable method for ER measurement. For PR determination on curettage material the DCC assay seems more accurate than EIA.

[Thrombi of the right heart. Value of thrombolytic therapy in mobile thrombi]

Seven patients with mobile right heart thrombi, 4 floating and 3 pediculated, were recensed between 1985 and 1990. Two patients were admitted for congestive cardiac failure (Group I) and 5 patients for pulmonary embolism (Group II). Both patients in Group I were treated with heparin without complications. In one case, the size of the thrombus decreased in 10 days whereas, in the second case, it disappeared within 8 days. In Group II, the first patient underwent successful thrombectomy. The other four patients were given thrombolytic therapy (UK = 2, rt-PA = 2) associated with appropriate doses of heparin. In the two patients given UK (3M units the first day followed by 1.2 M units per day for 4 days) the thrombus disappeared in the first 48 hours of treatment. One patient had a recurrent pulmonary embolism after 2 hours' treatment; both patients had a fall in haemoglobin of 3 cg/ml at the second day. The second patient died at the 5th day. In the two patients treated by rt-PA (100 mg/7 hours) the thrombus disappeared within 4 hours of starting therapy. One patient had a probable recurrent pulmonary embolism. Both patients had a fall in haemoglobin of 3 cg/ml at the 2nd day of treatment. Right heart thrombi are rare (168 cases in the literature of which 111 were mobile). The prognosis seems to be related to echocardiographic appearances: mortality of mural thrombi is about 4% compared with 50% in mobile thrombi. Very mobile "worm-like" masses are therapeutic emergencies because of the risk of embolism (about 68%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Enzymatic activities of the mitochondrial respiratory chain in child cardiomyopathies. 34 cases prospectively studied by endomyocardial biopsy]

The arguments in favour of mitochondrial pathology of certain childhood cardiomyopathies (multi tissue involvement, lactic acidosis, histochemical abnormalities of skeletal muscle) are indirect and may be absent in isolated cardiomyopathy. The authors therefore set up a prospective study of enzyme activity of the mitochondrial respiratory chain directly by endomyocardial biopsy. Fifty children aged 2 months to 16 years were included. Thirty four had cardiomyopathy which was dilated and hypokinetic with thin walls in 21 cases, restrictive in 2 cases, and hypertrophic in 11 cases; the remaining 16 children had either normal hearts (13 catheterised for other reasons) or myocardial hypertrophy due to pulmonary or aortic stenosis (3 cases). Both ventricles were evaluated in 3 cases; macro-surgical biopsies were obtained in 6 cases and skeletal muscle biopsy was obtained in 9 cases. The results indicate the method to be reliable with no difference between the micro and macro biopsies. The absolute values of enzyme activity were too variable to serve as quantitative parameters but some ratios of activity were remarkably stable and allowed a qualitative assessment which was all the more accurate when identical values were obtained in the myocardium, skeletal muscle and liver. The mitochondrial respiration was independent of ventricular pressures and of the type (right or left) of ventricle. Enzyme activity was nearly always normal in dilated cardiomyopathy (20/21) which suggests that it was unaffected by dilatation of the heart and by abnormal myocardial contractility. The results could be normal in myocardial hypertrophy and in valvular stenosis and in over half the cases of hypertrophic cardiomyopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

Neisseria gonorrhoeae prepilin export studied in Escherichia coli

The pilE gene of Neisseria gonorrhoeae MS11 and a series of pilE-phoA gene fusions were expressed in Escherichia coli. The PhoA hybrid proteins were shown to be located in the membrane fraction of the cells, and the prepilin product of the pilE gene was shown to be located exclusively in the cytoplasmic membrane. Analysis of the prepilin-PhoA hybrids showed that the first 20 residues of prepilin can function as an efficient export (signal) sequence. This segment of prepilin includes an unbroken sequence of 8 hydrophobic or neutral residues that form the N-terminal half of a 16-residue hydrophobic region of prepilin. Neither prepilin nor the prepilin-PhoA hybrids were processed by E. coli leader peptidase despite the presence of two consensus cleavage sites for this enzyme just after this hydrophobic region. Comparisons of the specific molecular activities of the four prepilin-PhoA hybrids and analysis of their susceptibility to proteolysis by trypsin and proteinase K in spheroplasts allow us to propose two models for the topology of prepilin in the E. coli cytoplasmic membrane. The bulk of the evidence supports the simplest of the two models, in which prepilin is anchored in the membrane solely by the N-terminal hydrophobic domain, with the extreme N terminus facing the cytoplasm and the longer C terminus facing the periplasm.

In vitro combination of high dose busulfan with radiotherapy on medulloblastoma cells: additive effect without potentiation

The aim of this in-vitro study was to evaluate the combination of busulfan with radiotherapy on TE-671 human medulloblastoma cells since unexpected clinical toxicity of busulfan was reported during the treatment of brain tumors, suggesting a possible radiopotentiation. The cytotoxicity of busulfan was determined by using colony forming assays, and doses inducing growth inhibitions of 10, 20 and 50% were selected to be tested in association: 6, 12 and 32 mumol/l for busulfan and 0.5, 1 and 3 Gy for irradiation. All possible combinations were considered within this frame and the results showed that the combination of busulfan with radiotherapy exerted an additive effect without potentiation.

[Molecular bases of virulence in Neisseria gonorrhoeae]

Gonorrhea remains of clinical concern, due to its frequency, complications, sequelae, increasing prevalence of antibiotic-resistant strains and absence of vaccine. A better understanding of the first stages of infection as well as of mechanisms of escape to immune response appears important. Many pathogenic bacteria express pili on their all surfaces. These structures mediate binding of bacteria to host tissues. Furthermore, gonococcal pili are submitted to a high rate antigenic variation, allowing the escape to host immune response. Pilin antigenic variation occurs by DNA recombination between one of the silent partial variant gene segments and an expressed pilin genes. We have shown that transformation of living bacteria by DNA liberated from lysed cells is a critical strep for antigenic variation. This constitutes the first specific function for a DNA transformation system. Piliation and virulence can change with culture conditions. This observation suggests that pilin expression would be subjected to an adaptative response. We have identified and characterized two genes which act in trans to regulate pilus expression. They determine synthesis of a response regulator and a membrane located sensor. They appear to regulate expression of other genes, possibly also involved in virulence. We present evidence for several environmental factors which may control the degree of piliation.

[Right pulmonary artery arising from the proximal ascending aorta. A model of reflex pulmonary hypertension of the left lung?]

The right pulmonary artery arising from the proximal ascending aorta is a rare and severe malformation. This retrospective study of 11 children with this condition was undertaken to determine the conditions of diagnosis, to analyse the results of surgery, and, above all, to clarify the mechanism of the left pulmonary arterial hypertension which was always present. Ten of these patients were 4 to 90 days old. All had severe congestive cardiac failure with iso- or suprasystemic left pulmonary arterial hypertension. The only associated lesions were ventricular septal defect (1 case) and patent ductus arteriosus (7 cases). None of the patients had significant left-to-right shunts and only one had left atrial hypertension: this patient died before surgery could be performed. The other 9 patients underwent surgical correction and the pulmonary pressures immediately fell to normal or almost normal values. The child with the ventricular septal defect died of infection 6 weeks after surgery. The 8 survivors are doing well 1 month to 12 years later and left pulmonary pressures are normal in all, including those (5 cases) with a stenosed (4 cases) or completely occluded right pulmonary arterial circulation (1 case) and in 1 patient with obstructive vascular disease. The eleventh patient was very different: she had no signs or symptoms until 2 years of age, when a right pulmonary obstructive arterial disease but with normal left pulmonary pressures was documented. She was not operated on and remains well nine years later.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term follow-up of elderly patients with severe aortic stenosis treated by balloon aortic valvuloplasty. Importance of haemodynamic parameters before and after dilatation

Early and late prognosis after percutaneous balloon aortic valvuloplasty (PBAV) was assessed in 38 consecutive elderly patients (mean age, 78.5 +/- 6.1 years). Significant valve opening was achieved in 35 patients. The hospital mortality was 8% (three patients); two other patients died within the first month and three underwent aortic valve replacement. At 2 years follow-up, there were 10 additional deaths (seven cardiac deaths) and five patients had symptom recurrence managed by aortic valve replacement (3) or repeat PBAV (2). Overall, six patients underwent surgery without untoward events and six had repeat PBAV. Only two out of six patients with repeat PBAV had sustained improvement; one was referred to surgery and the remaining three died soon after the second PBAV. One- and 2-year survival were respectively 72 and 62% and percentage of survivors with persistent improvement 68 and 41%. Although aortic valve area after PBAV was associated with outcome, predictors of poor long-term prognosis were primarily related to the pre-operative haemodynamic status. Patients with pulmonary resistances greater than 400 dynes cm-1 s-5 had the poorest outcome (chi 2 = 18.4-P less than 0.0001). Overall, signs of heart failure were predictors of poor long term follow-up. These data indicate that long-term success of PBAV is mainly related to the left ventricular dysfunction noted prior to intervention.

Unusual encephaloclastic lesions with paraventricular calcification in congenital rubella

We report an unusual case of congenital rubella. The infant was suffering from a serious encephalopathy, and both prenatal echography and neonatal CT scan showed passive ventriculomegaly with a calcified periventricular border. Usually, such lesions are strongly suggestive of cytomegalovirus (CMV) infection and have never previously been reported in congenital rubella. Classic cerebral lesions in rubella are related to a prominent obstructive vasculopathy. Conversely, encephaloclastic lesions in CMV infection are likely related to a necrosis of brain parenchyma following upon an initial ventriculitis, and perhaps also to a disturbance of neuronal proliferation. Recently, Carey described a neonate with proven congenital rubella and cranial ultrasound findings typical of ventriculitis. However, in spite of the close similarity between our patient's lesions and the typical CMV lesions, we think it's impossible to assert similar pathogenic mechanisms. Actually, it's quite conceivable that only a severe or extensive vasculopathy can lead to brain atrophy with periventricular calcification in congenital rubella.