Possibility of conservative local treatment after combined chemotherapy and preoperative irradiation for locally advanced noninflammatory breast cancer

PURPOSE

The aims of this prospective study were to evaluate the outcome and the possibility of breast conservation therapy for patients with locally advanced noninflammatory breast cancer after primary chemotherapy followed by external preoperative irradiation.

METHODS AND MATERIALS

Between April 1982 and June 1990, 97 patients with locally advanced nonmetastatic and noninflammatory breast cancer were treated. The median follow-up was 93 months from the beginning of treatment. The induction treatment consisted of four courses of chemotherapy (doxorubicin, vincristine, cyclophosphamide, 5-fluorouracil) followed by preoperative irradiation (45 Gy to the breast and nodal areas). A fifth course of chemotherapy was given after irradiation therapy. Three different loco-regional approaches were proposed, depending on the tumoral response. In 37 patients (38%) with residual tumor larger than 3 cm in diameter or located behind the nipple or with bifocal tumors, mastectomy and axillary dissection were performed. Sixty other patients (62%) benefited from conservative treatment: 33 patients (34%) achieved complete remission and no surgery was done but additional radiation boost was given to the initial tumor bed; 27 patients (28%) who had a residual mass less than or equal to 3 cm in diameter were treated by wide excision and axillary dissection followed by a boost to the excision site. After completion of local therapy, all patients received a sixth course of chemotherapy. A maintenance adjuvant chemotherapy regimen without anthracycline was prescribed (12 monthly cycles).

RESULTS

The 5-year actuarial loco-regional relapse rate was 16% after radiotherapy alone, 16% following wide excision and radiotherapy, and 5.4% following mastectomy. The 5-year loco-regional relapse rate was significantly higher after conservative local treatment (wide excision and radiotherapy, and radiotherapy alone) than after mastectomy (p= 0.04). After conservative local treatment, the 5-year breast conserving rate of patients with loco-regional disease-free status was 84%. For all patients included in this study, the 5-year breast-conserving rate of those who were loco-regional disease-free was 52%. In multivariate analysis, the possibility of breast conservative treatment was significantly related to the initial tumor size and age (more conservative treatment for tumor size < 6cm and age < 50 years). Five- and 10-year overall survival rates and disease-free survival rates were 80, 69, 73, and 61% respectively. Five- and 10-year overall survival rates were not influenced by the local treatment (conservative vs. nonconservative local treatment, p = 0.9). On the other hand, local failure significantly decreased the 5- and 10-year overall survival rates (p , 0.0001). In multivariate analysis, three factors had a significant impact on overall survival and disease-free survival: tumor response after induction chemotherapy, initial tumor size, and clinical stage. Arm lymphedema was noted in 12.5% (8 out of 64) of the patients treated with axillary dissection and in 3% (1 out of 33) without axillary dissection. Cosmetic results were satisfactory in 79% of patients after wide excision and radiotherapy and in 71% of patients treated by radiotherapy alone.

CONCLUSIONS

Induction chemotherapy followed by preoperative irradiation may permit the selection of some patients with locally advanced breast cancer for conservative treatment. However, the impact of this treatment modality on long-term survival remains to be established.

Fast neutrons in the treatment of grade IV astrocytomas

In 1981, the Hôpital Tenon group and the Orléans neutron therapy team initiated a collaborative study for the treatment of grade IV astrocytomas using a combination of photons and neutrons. Neutrons were used as boost in a reduced volume. Doses were progressively increased from 6 to 7 Gy and later up to 8 Gy. Since October 1994, a neutron boost of 7.5 Gy has been delivered. At the time of evaluation, 294 patients had a minimum follow-up of 12 months. Univariate analysis indicated that clinical status, tumor location and photon fractionation scheme had no significant influence on survival. In contrast, age, surgical procedure and neutron dose were found to be prognostic factors. In a multivariate analysis, the prognostic value of the surgical procedure disappeared and the only remaining independent prognostic factors up to 11 months after treatment (P = 0.001) were age and the neutron dose. As far as neutron dose was concerned, survival increased with dose from 6 to 7 Gy up to 15 months. However, after 15 months, there was no longer any benefit in survival for the patients treated with 8 Gy, and complications related to overdosage began to appear. There was a long-term survival group: 55 patients were alive 18 months after treatment (18%). The median survival was 26.7 months. The best survival was observed for patients treated with a neutron boost of 7 Gy in eight fractions over 11 days (25 vs 18%). The present study demonstrates the feasibility of a combination of photons (30 Gy total brain) followed by a neutron boost (7 Gy) in the treatment of high-grade astrocytomas. The results are in good agreement with the published data. In the literature, age and surgical procedure are currently considered as the most important prognostic factors. The prevalence of neutron dose over these two other prognostic factors, as shown in this study, is an important additional argument in favor of the use of neutrontherapy in the management of these tumors. A possible benefit when combining external fast neutrontherapy with boron neutron capture therapy (BNCT) could reasonably be expected.

Interstitial pneumonitis following autologous bone-marrow transplantation conditioned with cyclophosphamide and total-body irradiation

PURPOSE

To assess the influence of different total-body irradiation (TBI) regimens on interstitial pneumonitis (IP), we retrospectively analyzed our clinical data concerning an homogeneous group of patients conditioned with cyclophosphamide (CY) alone and single-dose or fractionated TBI before autologous bone-marrow transplantation (ABMT).

METHODS AND MATERIALS

One hundred eighty-six patients with acute nonlymphoblastic leukemia (n = 101), acute lymphoblastic leukemia (n = 62), chronic myeloid leukemia (n = 11), non-Hodgkin's lymphoma (n = 10), and multiple myeloma (n = 2) referred to our department between May 13, 1981 and September 16, 1992, underwent TBI before ABMT. The male-to-female ratio was 123:63 (1.95), and mean and median age was 33 +/- 12 (6-63 years) and 35 years, respectively. Cyclophosphamide alone (60 mg/kg/day on each of 2 successive days) was used as conditioning chemotherapy in all patients. Patients were irradiated according to two techniques: either with single-dose (STBI) (n = 124; 10 Gy administered to the midplane at the level of L4, and 8 Gy to the lungs) or with fractionated (FTBI) (n = 62; 12 Gy in 6 fractions over 3 consecutive days to the midplane at the level of L4, and 9 Gy to the lungs) TBI. The mean instantaneous dose rate was 0.057 +/- 0.0246 Gy/min (0.0264-0.1692 Gy/min). It was < or = 0.048 Gy/min in 48 patients (LOW group), > 0.048 and < or = 0.09 Gy/min in 129 patients (MEDIUM group), and > 0.09 Gy/min in 9 patients (HIGH group). The median follow-up period was 5 years (24-120 months).

RESULTS

In January 1994, the 5-year overall (including all causes of death) and disease-free survival (DFS) rates were 50 and 48%, respectively. The 5-year DFS was 47.9% in the STBI group, and 47.8% in the FTBI group (p = 0.77). It was 44% in the HIGH group, 53% in the MEDIUM group, and 34% in the LOW group (LOW vs. MEDIUM, p = 0.009). The 5-year IP incidence was 17% in all patients, 16% in the STBI group and 18% in the FTBI group (p = 0.37), but it was significantly higher in patients receiving high instantaneous dose rate TBI (56% in the HIGH, 13% in the MEDIUM, 20% in the LOW groups; HIGH vs. MEDIUM, p = 0.002). However, sex (p = 0.37), age (18% for > 20 vs. 10% for < or = 20 years, p = 0.37), and body weight (> 60 kg vs. < or = 60 kg, p = 0.09) did not influence the IP incidence in univariate analyses. Multivariate analysis (Cox model) revealed that the instantaneous dose rate (p = 0.05), and the age (p = 0.04) were the two independent factors influencing the incidence of IP.

CONCLUSION

This retrospective study including only the patients transplanted with ABMT conditioned with CY alone and STBI or FTBI concluded that instantaneous dose rate and age significantly influenced the incidence of IP, whereas sex, body weight, and fractionation did not.

[Radiosurgery by linear accelerators in the treatment of 84 arteriovenous malformations]

We have treated in 1990 and 1991, 84 arteriovenous malformations (AVMs) by radiosurgery. Irradiation was realized by 5 to 7 arcs with 15 MV X rays circular minibeams of a GE-CGR Saturne 43 Linac diameter, at 100 cm 6 to 20 mm; the Betti arm chair and the Talairach frame. The prescribed peripheral dose containing the nidus was 25 Gy corresponding to the 60-70% isodose range (100% was the maximum dose). For the irradiation planning we used the 'associated targets methodology' and the ARTEMIS-3D TPS, both of which have been developped in the radiotherapy departement of the Tenon hospital. Evaluation was performed in February 1995, the follow-up range was 38 to 62 months. In 1990, 46 cases were treated for cure and were all evaluable, whereas in 1991, among the 38 irradiated cases one patient was not evaluable because of lack of arteriographic control. Thus this series consisted in 84 evaluable cases. The overall obliteration rate was 65/84 (78%), partial obliteration was seen in 18/84 (21%) and no change in 1 case. According to AVM volume, obliteration rate was: AVMs < 4200 mm3: 82% (46/56). For lesions > 4200 mm3 it was 68% (19/28). In one isocenter irradiation, the obliteration rate was 42/47 (89%); whereas it was 23/37 (62%) in multi-isocenters treatments. The obliteration rate was better for not previously treated cases: 39/44 (89%) than for previously treated nidus (mostly embolisation) 65% (26/40). In 23 spheroid AVMs obliteration rate was 87% (20/23) in 43 ellipsoid AVMs the obliteration rate was 77% (33/43); and in irregular rounded nidus, it was 67% (12/18). The peripheral dose of 25 Gys has been used in 78 cases (93%), the obliteration rate was 63/78 (81%); in 6 other cases treated with 15-23.5 Gy, it was 2/6 (33%). We observed two recurrences of haemorrhage at 4 and 6 months after radiosurgery (recurrent haemorrhage rate 2/84 = 2.4%) with total neurological recovery in one of the two patients. One patient died of myocardial infarctus 11 months after radiosurgery (there was a partial obliteration of his AVM at 8 months after radiosurgery). There was no AVM related death. One patient developed an epilepsy.

Epidermoid carcinoma of the anal margin: 17 cases treated with curative-intent radiation therapy

Between 1973 and 1991, 17 patients with epidermoid carcinoma of the anal margin without evidence of distant metastasis were treated with curative-intent radiation therapy (RT). There were nine T1-tumors, six T2-, one T3- and one T4-tumor; two patients presented with inguinal node involvement: one N1 and one N3. Nine patients underwent prior incomplete local excision (six with microscopic involvement of surgical margins and two with macroscopic residual disease). The radiation dose to the tumor was 60-70 Gy; the radiation dose to the inguinal lymph nodes was 40-45 Gy in N0, and 50-60 Gy for involved inguinal nodes. The 5- and 10-year cancer-specific survival rates were 86.2% and 77.5%, respectively. The same probabilities were 100% and 100% for T1-tumors, 60% and 40% for T2-tumors. Severe complications occurred in two patients, one anal radionecrosis requiring a colostomy and one permanent anal incontinence after local excision, which was non-related to irradiation. For the cured patients, the sphincter preservation rate after 5 years was 82% (9/11). In univariate analysis and in Cox multivariate analysis, the cancer-specific survival rate was influenced by one factor: the tumor size.

Conservative versus nonconservative treatment of epidermoid carcinoma of the anal canal for tumors longer than or equal to 5 centimeters. A retrospective comparison

BACKGROUND

The role of radiotherapy alone in the sterilization of anal canal epidermoid carcinomas of 5 cm or more remains to be assessed. Thus, the outcomes of patients treated with radiotherapy alone (RT) versus those treated with preoperative radiotherapy and surgery (RS) were compared retrospectively.

METHODS

Between 1972 and 1990, 185 patients were treated with curative intent either with RT alone (n = 147) or with RS (n = 38). The Mean tumor length was 6.18 +/- 1.14 cm and was significantly longer in the RS group (6.55 +/- 1.29 cm) than in the RT group (6.08 +/- 1.08 cm) (P = 0.02). The median follow-up was 77 +/- 57 months and 93 +/- 60 months (P = 0.23) for the RT and RS groups, respectively. For the RT group, the first course of radiotherapy was 40 to 45 Gy in the pelvis for 4 to 5 weeks; after a rest of 4 to 6 weeks, radiotherapy was boosted an additional 15 to 20 Gy for 2 weeks. The RS patients received 40 to 45 Gy in the pelvis for 4 to 5 weeks, then received surgery after a median period of 54 days.

RESULTS

The overall 10-year cancer specific survival rates were 58% in the RT group and 66% in the RS group (P = 0.48). The T-stage 10-year cancer specific survival rates were 68% in the RT group and 67% in the RS group for T2 tumors (P = 0.96); 57% in the RT group and 53% in the RS group for T3 tumors (P = 0.85); and 42% in the RT group and 40% in the RS group for T4 tumors (P = 0.05). In the RS group, the local control rate was 75% (3/4) for T2 tumors; 74% (17/23) for T3 tumors; and 82% (9/11) for T4 tumors. In the RT group, the local control rate was 77% (34/44) for T2 tumors; 70% (58/82) for T3 tumors; and 60% (12/20) for T4 tumors. In the RT group, the anal conservation rate was 61% (27/44) for T2 tumors, 59% (48/82) for T3 tumors, and 55% (11/20) for T4 tumors. Local tumoral control and a functioning anus were present in 72 out of 147 (49%) patients [52% (23/44) for T2 patients, 52% (43/82) for T3 tumors, and 30% (6/20) for T4 patients]. In the RS group, the grade 3 complication rate was 9% (13/146) and in the RS group, 5% (2/38).

CONCLUSION

For patients with T4 tumors, preoperative radiotherapy and surgery seemed to be better in terms of survival and local tumor control rate, but the difference was not significant probably because the number of patients in the RS group was small. For these large tumors, the treatment should probably be more aggressive, combining chemotherapy and radiation therapy, but the increase of local control in relation with the addition of cytotoxic chemotherapy to irradiation is not proved.

Radiation therapy with or without surgery in the management of low-grade brain astrocytomas. A retrospective study of 120 patients

From 1977 to 1988, 120 consecutive patients with a diagnosis of low-grade astrocytoma were referred to our department for radiotherapy. Fourty-one patients (group 1) underwent surgery and post operative external radiation therapy (2 gross total resections and 39 subtotal resections). Sixty-nine patients underwent exclusive external radiotherapy (group 2). In ten patients, the irradiation was delivered by stereotactic implantation of iridium-192 wires into the tumor with or without external irradiation (group 3). Ten had pilocytic astrocytomas (mean age, 24 years) and twenty had microcystic astrocytomas (mean age, 35.4 years). The 5- and 10-year survival rates were 55.6% and 44.4%, respectively and 55% and 48%. Ninety astrocytomas were classified as "ordinary" astrocytoma (mean age, 36.8 years). The 5- and 10-year overall survival rates were 51% and 20.5%, respectively. The same probabilities at 5 and 10 years were 65% and 37% respectively, for group 1, 38.8% and 12.7% for group 2 and, 78.8 and 22.5% for group 3. In multivariate analysis, two prognostic factors had a significant impact on overall survival: IK score (IK < 90 vs IK > or = 90, p = 0.0001), surgical resection (surgical resection and post operative radiotherapy vs radiation therapy alone, p = 0.012). However, the patients who underwent surgical resection were those in the best condition, having tumors that were easily accessible and less invasive.

Synchronous and metachronous head and neck carcinomas

BACKGROUND

The incidence of head and neck cancer is increasing. To improve the survival of head and neck cancer patients, an effective program of screening and/or chemoprevention of second malignancies is essential. An analysis of the incidence, time to development, and risk factors of second malignant tumors in head and neck cancer patients can contribute to the design of effective screening and chemoprevention programs.

METHODS

Eight hundred, fifty-one patients with initial squamous cell carcinoma of the larynx (n = 224), tonsils (n = 189), pyriform sinus (n = 165), oral cavity (n = 129), mobile tongue (n = 72), and base of tongue (n = 72) treated from 1978 to 1990 were analyzed for the presence of a second malignancy after initial therapy. Of these 851 patients, 544 (64%) were documented smokers and 35 (4%) were nonsmokers. No smoking information was available for 272 patients. Four hundred, fifty-four patients (53%) were consumers of alcohol and 64 patients (8%) were nondrinkers. Alcohol consumption information was not available for 333 patients.

RESULTS

One hundred, sixty-two (19%) second head and neck carcinomas occurred in the original 851 patients. Sixty-six patients (41%) had synchronous tumors, and 96 patients (59%) had metachronous tumors. The probability of developing a second metachronous cancer 5-years after undergoing treatment for the initial head and neck cancer was 22%. Borderline statistical significance was observed in the 5-year second cancer incidence based on the site of the initial primary cancer (46% for the base of tongue, 34% for the pyriform sinus, 23% for the larynx, 18% for the oral cavity, 15% for the tonsils, and 10% for the mobile tongue). Tobacco smoking (3% for nonsmokers vs. 26% for < or = 20 pack-years vs. 42% for > 20 and < or = 40 packs/year vs. 30% for > 40 packs/year of smoking) and the consumption of alcohol (5% for non-drinkers vs. 32% for drinkers) were both statistically significant in predicting the likelihood of developing a second malignancy. Multivariate analysis revealed that the two independent variables that influenced the occurrence of a second metachronous cancer were the anatomic site of the original primary cancer and patient age. The survival rate after the second cancer was influenced significantly by the site of the second cancer (20% for a second head or neck cancer, 3% for a second esophageal cancer, and 2% for a second lung cancer). Continued smoking (20% for non-smokers vs. 5% for smokers) and continued alcohol consumption (27% for nondrinkers vs. 6% for drinkers) also adversely influenced the survival after the occurrence of a second cancer.

CONCLUSIONS

This study confirms the high rate of second cancers in patients with initial head and neck malignancies. The development of a second malignancy is almost always fatal. Screening programs and chemoprevention trials should be directed toward cancer patients with initial head and neck cancers. Only the small subset of nonsmokers and nondrinkers should be excluded from such trials.

Kidney mobility during respiration

Radiotherapy treatment planning needs optimum definition of the target volume in its relative position to normal tissue. The motion of the kidneys during respiration has not been well quantified. They move in a tilted coronal and sagittal plane. Using fast MRI while patients held their breath we quantified the movements of the kidneys. Fourteen patients volunteered for the study. Nine MRI images of the kidneys for one volunteer were done: three in the axial plane (all in deep inspiration) and six in the coronal plane (three in deep inspiration, three in deep expiration). The maximal vertical motion of the superior pole from its end-expiratory to its end-inspiratory position is 39 mm (43 mm for the inferior pole). In deep inspiration or deep expiration the positions of the right and left kidneys appear reproducible. The mean deviation of kidney movement is less than 4 mm in all three dimensions (range, 0-6.9). For tumors close to the kidney, we advocate respiration gated radiation therapy so as to minimize the movement of this very radiosensitive structure.

Epidermoid carcinoma of the anal canal. Results of curative-intent radiation therapy in a series of 270 patients

BACKGROUND

Epidermoid carcinoma of the anal canal is an uncommon disease, and most institutions have only a small series of patients. The current study of a large series of patients treated with radiation therapy in a single institution evaluates the outcome, prognostic factors, and the late complications for these patients.

METHODS

From 1972 to 1991, 270 patients with anal canal epidermoid carcinoma without evident distant metastasis were irradiated with curative intent in the Radiotherapy Department of Tenon Hospital. The sex ratio was 1 man/5.7 women, with a mean age of 67.5 years. The histology included 59.6% well-differentiated epidermoid carcinoma, 32.2% moderately or poorly differentiated epidermoid carcinoma, and 8.2% cloacogenic. The T-classification was: T1: 8.5%; T2: 51.1%; T3: 30.4%; T4: 10%. Abnormal inguinal lymph nodes were present in 12.5% of the patients. Patients were irradiated by external beam. They received a first course of photon irradiation consisting of (mostly 18 mV or 25 mVl; some Co60 or 6 mV) 40-45 Gy (box technique) in the pelvis for 4-5 weeks. After a rest of 4-6 weeks, a second course of 15-20 gy in 2 weeks was given through a perineal field by an electron beam of suitable energy. When rectal involvement was important, a four-field, small box technique was used. Fourteen patients were given a booster irradiation of 30 Gy by interstitial brachytherapy (Iridium 192 sources), and four patients were treated with interstitial brachytherapy alone, to a mean dose of 62.5 Gy.

RESULTS

At 5 and 10 years, determinate survival rates were: T1: 86% and 86%; T2: 86.2% and 82.5%; T3: 60.1% and 56.8%; T4: 45% and 45%, respectively. The overall local control rate was 80%. The overall anal conservation rate was 67%. In 154 patients (57%), the anus had maintained its normal function. At 5 and 10 years, determinate survival was 76% and 73.7%, respectively, for N0 and 53.5 and 53.5% for clinically involved inguinal lymph nodes. According to the log-rank test, survival comparisons between T2 and T3 classifications and of tumor sizes less than or equal to 4 cm in length and greater than or equal to 5 cm in length were significant (P = 0.0001 and P < 0.0001, respectively). The presence of clinical abnormal inguinal lymph nodes had a significant negative influence on survival rates (P = 0.047). Multivariate analysis indicated that T-classification and tumor size in centimeters were the only predictive variables. Nonpredictive variables included nodal status, histology, age, total dose, overall treatment time, and irradiation technique. The grade 3 complication rate requiring surgical treatment was 27/270 (10%), considering all patients (27/190 represents a 14% rate for patients who had local tumor control after radiation therapy alone without secondary salvage amputation). There was no significant relationship between complication rate and the aforementioned variables. Because of the homogeneity of the irradiation doses, no significant relationship was found between dose, local control rate, or complication rate.

CONCLUSIONS

After radiation therapy, recognizing the distinction between tumor sizes of less than or equal to 4 cm in length and more than 4 cm in length (which is not considered in TNM Classification criteria [International Union Against Cancer, 1987]) could help to improve treatment strategies. For tumors more than 4 cm in length and/or with clinically involved lymph nodes, the treatment should be more extensive with combined chemotherapy and radiation therapy, but the increased local control with the addition of cytotoxic chemotherapy to irradiation has not been proven.

A 3-D radiosurgical methodology for complex arteriovenous malformations

A 3-D methodology, the associated targets methodology, for planning radiosurgical irradiations of complex arteriovenous malformations (AVMs) is presented. It uses the ARTEMIS-3D treatment planning system and has been devised and adopted by our group since January 1990. Its main features are: (a) prescription and delivery of a minimal target dose on the surface of the lesion, corresponding to a 60-70% isodose range. The dose to adjacent functional neurological structures is taken into account as well as the maximum dose to the lesion; (b) An optimisation approach consisting of obtaining the optimal superimposition of the isodose surface and the 3-D contour of the lesion and sharp fall-offs by interactive manipulation of the treatment parameters. The clinical choice of the treatment plan is based on a compromise between the optimal reference isodose surface encompassing the lesion and the minimisation of the volumetric dose fall-off. In complex AVMs the angiographic results have been significantly improved in comparison with our previous experience because of the better achieved lesion encompassing.

The influence of arc weights on the dose distribution for single target radiosurgery

To stereotactically irradiate ellipsoidal inclined arteriovenous malformations (AVMs) with a single isocenter one can use an adjusted inclined irradiation space with a reduced angular range of arcs. If one uses the maximum available irradiation space it is necessary to weight some of the arcs in order to closely encompass the lesion. It has been found that there is a relationship between the lesion inclination angle beta and the weights of arcs. Conversely when the beta angle is known, the weights of the arcs can be determined in advance by means of weighting vectors. The dose volume analysis shows that the isodose volumes remain constant for the different weighting vectors except for the 10% isodose volume which increases slightly as the linear weighting vector's slope alpha increases. Moreover, this procedure permits the optimization of the superimposition between the lesion and the reference isodose. These results enable the construction of an "a priori knowledge" database that can be included in an optimization algorithm procedure.

[Cancer of the anal canal; role of radiotherapy and combinations of chemotherapy and radiotherapy]

Carcinoma of the anal canal is a rare disease, more common in women than in men. The mean age distribution at presentation is about 60 years. The natural history is mainly loco-regional, distant metastases being uncommon. Histologically, most cancer are of the squamous cell type of different keratinization. The pre treatment evaluation is mainly performed by methodical clinical examination. There is no widely accepted staging system for these tumours. Three statistically significant prognostic factors are admitted: tumour size, regional nodal involvement and histological grade. The french school (Tenon, Institut Gustave Roussy, Institut Curie, Lyon) and the experience at the "Princess Margaret Hospital" at Toronto have shown that irradiation of these tumours is an adequate therapy. In Europe, irradiation has always played a more important role in the therapy of these tumours, than in North America where surgery was often preferred as the initial therapy. With the introduction of combined modality treatment, the use of pre-operative concomitant radiochemotherapy, in North America, has again changed the treatment policy towards a conservative radiotherapeutic approach. The present study analyses the modalities and the results from radiation therapy alone and the preliminary results from concomitant irradiation and chemotherapy.

Multidisciplinary treatment approach to locally advanced non-inflammatory breast cancer using chemotherapy and radiotherapy with or without surgery

Between April 1982 and December 1987, 82 locally advanced non-metastatic and non-inflammatory breast cancers were treated (42 stage IIIA, 40 stage IIIB). The median follow-up is 70 months from the beginning of the treatment. The initial treatment consisted of 4 courses of chemotherapy (doxorubicin, vincristine, cyclophosphamide, 5-fluorouracil) followed by irradiation (45 Gy to the breast and nodal area). A fifth course of chemotherapy was given after radiation therapy. Three different locoregional approaches were proposed depending on the tumoral response. In 32 patients (39%) with residual tumor larger than 3 cm in diameter or located behind the nipple or with multifocal tumors, mastectomy and axillary dissection were performed. Fifty other patients (61%) benefited from conservative treatment: 32 patients (39%) achieved complete remission and received a boost to the initial tumor bed; 18 patients (22%) who had a residual mass less than or equal to 3 cm in diameter were treated by tumorectomy and axillary dissection followed by a boost to the tumorectomy site. After completion of local therapy, all patients received a sixth course of chemotherapy. A maintenance adjuvant chemotherapy regimen without anthracycline was prescribed (12 monthly cycles). Three- and 5-year disease-free survival rates were 81.7% and 72% respectively. Five-year locoregional relapse rate (with or without other sites of failure) was 8.8%. In a multivariate analysis, disease-free survival was significantly influenced by the N-stage (p < 0.0001), initial tumor size (p = 0.01), and tumor response after initial chemotherapy (p = 0.02). Five-year breast conservation probability was 58.4%.(ABSTRACT TRUNCATED AT 250 WORDS)

Preoperative radiation therapy and surgery in the treatment of "bulky" squamous cell carcinoma of the uterine cervix (stage Ib, IIa, and IIb operable tumors)

Forty-two women with "bulky" squamous cell carcinoma of the uterine cervix, larger than 5 cm, were treated between 1982 and 1988. The median follow-up was 5 years (from 37 to 106 months). The age range was from 25 to 77 years (mean: 49). There were 14 stage Ib, 5 stage IIa, and 23 stage IIb operable patients. Forty grays were delivered at mid-plane of the pelvis (23 fractions in 31 days) using the four-field technique (6-18 MV). External beam radiation therapy was followed by 20 Gy of intracavitary radiation therapy. Forty-eight days later total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) and bilateral pelvic lymphadenectomy were performed. The 3- and 5-year disease-free survival was 83 and 81%, respectively. The 5-year locoregional control rate was 83%. Thirteen patients suffered from mild to severe complications (31%) but there were only two long-term (5%) complications.