Squamous cell carcinoma of the larynx with subglottic extension: is larynx preservation possible?

PURPOSE

Squamous cell carcinoma of larynx with subglottic extension (sSCC) is a rare location described to carry a poor prognosis. The aim of this study was to analyze outcomes and feasibility of larynx preservation in sSCC patients.

PATIENTS AND METHODS

Between 1996 and 2012, 197 patients with sSCC were treated at our institution and included in the analysis. Stage III-IV tumors accounted for 76%. Patients received surgery (62%), radiotherapy (RT) (18%), or induction chemotherapy (CT) (20%) as front-line therapy.

RESULTS

The 5-year actuarial overall survival (OS), locoregional control (LRC), and distant control rate were 59% (95% CI 51-68), 83% (95% CI 77-89), and 88% (95% CI 83-93), respectively, with a median follow-up of 54.4 months. There was no difference in OS and LRC according to front-line treatments or between primary subglottic cancer and glottosupraglottic cancers with subglottic extension. In the multivariate analysis, age > 60 years and positive N stage were the only predictors for OS (HR 2, 95% CI 1.2-3.6; HR1.9, 95% CI 1-3.5, respectively). A lower LRC was observed for T3 patients receiving a larynx preservation protocol as compared with those receiving a front-line surgery (HR 14.1, 95% CI 2.5-136.7; p = 0.02); however, no difference of ultimate LRC was observed according to the first therapy when including T3 patients who underwent salvage laryngectomy (p = 0.6). In patients receiving a larynx preservation protocol, the 5-year larynx-preservation rate was 55% (95% CI 43-68), with 36% in T3 patients. The 5-year larynx preservation rate was 81% (95% CI 65-96) and 35% (95% CI 20-51) for patients who received RT or induction CT as a front-line treatment, respectively.

CONCLUSION

Outcomes of sSCC are comparable with other laryngeal cancers when managed with modern therapeutic options. Larynx-preservation protocols could be a suitable option in T1-T2 (RT or chemo-RT) and selected T3 sSCC patients (induction CT).

Oral cavity squamous cell carcinoma in patients aged 80 or older: Risk factors, treatment, and outcome

6064

Background: We have recently reported a large series of patients aged ≥ 80 years showing that in this population about half of head and neck squamous cell carcinomas (SCC) are located in the oral cavity. There are no specific data on this cancer location outcome in elderly patients. Therefore, we report here the experience of two French cancer centers in the treatment of oral cavity SCC in patients aged ≥ 80 years. Methods: Two hundred sixty patients aged ≥ 80 years with a primary oral cavity SCC were included in this retrospective analysis. Results: Sex ratio was near to 1. The risk factor distribution was significantly different between men and women: tobacco/alcohol consumption (66.3% vs 15.8%, p < 0.001), history of leukoplakia/lichen planus/oral traumatism (10.8% vs 55.3%, p = 0.002). Two hundred patients received a loco regional (LR) treatment with a curative intent (surgery and/or radiotherapy), 29 with a palliative intent and 31 did not receive a LR treatment. Curative treatments were delivered according to the institution policy in 56 patients (28%).The median disease specific survival (DSS) was 16.9 months. In multivariate analysis, independent prognostic factors were stage (HR = 0.45 [0.29–0.69], p < 0.001), and curative intent of treatment (HR = 0.28 [0.17–0.45], p < 0.001). Median overall survival (OS) was 13.9 months. In multivariate analysis, the independent prognostic factors for OS were age (HR = 0.63 [0.33–0.76], p < 0.001), stage (HR = 0.61 [0.40–0.91], p = 0,016), and curative intent of treatment (HR = 0.41 [0.23–0.71], p < 0.001. In patients treated with a curative intent, the standard treatment was not associated with improved overall survival or disease specific survival as compared with those treated with an adapted treatment. However, prophylactic lymph node treatment in early stage cancer decreased the rate of nodal recurrence from 38% to 6% (p = 0.01). Conclusions: This study emphasizes the need for prospective evaluation of standard and adapted schedules in elderly patients with oral cavity cancer.

No significant financial relationships to disclose.

[Larynx preservation: nonsurgical approaches]

The question of larynx preservation is central in the management of patients with a carcinoma of the larynx or hypopharynx, especially to preserve the main functions of the larynx. In early stages (T1-earlyT2) Larynx preservation can generally be obtained with partial surgery or radiotherapy. Some other approaches such as exclusive chemotherapy require further investigations. In locally advanced and infiltrating larynx/hypopharynx carcinomas, (advancedT2-T3), several ways have been used to preserve the larynx including exclusive radiotherapy which can be improved by modified fractionation and acceleration. The efficacy of radiotherapy can be also markedly increased by adding concomitant cisplatin based chemotherapy, as reported recently in a large randomized trial. An alternative approach consisted in using induction chemotherapy (cisplatin-5FU) and followed by a local treatment adapted to the response to chemotherapy. The combined analysis of 3 such randomized trials (GETTEC, Veteran et EORTC) showed that this approach has to be used with caution, and could be safer in good responders to induction chemotherapy. Finally, larynx preservation is generally not proposed in patients with deeply infiltrating tumors and or tumor invading the cartilage or soft tissue in the neck (T4).

[Locoregional recurrences of HNSCC: place of re-irradiations]

Unresectable forms of HNSCC relapses occurring in a previously irradiated area are relatively common and may be difficult to manage from a therapeutic point of view. Full dose re-irradiation with concomitant chemotherapy constitutes an alternative to palliative chemotherapy. Indeed, the feasibility of this approach has been shown, and may be associated with a curative potential in a relatively low proportion of these relapses.

[CT and MRI aspects of 28 patients with cerebral radiation necrosis irradiated for ORL tumors: correlation with the radiation technique]

PURPOSE

To describe and correlate with radiation therapy the occurrence of cerebral radiation necrosis in patients irradiated for nasopharyngeal or ethmoidal tumor. Materials and Methods. From 1986 to 1998, 1 201 patients, 981 with nasopharyngeal tumors, and 220 with ethmoidal tumors were treated by radiotherapy. Twenty eight developed cerebral necrosis. MRI were performed in all patients and CT in 18 patients. Diagnosis was considered at imaging, and confirmed by follow-up.

RESULTS

The incidence of cerebral radionecrosis was 2.33%. The time interval between treatment and necrosis ranged from 2 months to 9 years. CT showed edema and/or focal enhancement in all cases except for 4 patients with normal CT examinations. MRI showed edema and/or abnormal focal punctate or gyriform enhancement in all patients. Lesions were localized in the temporal lobe (n=18), frontal lobe (n=9), pons (n=3) and optic nerve (n=2). The doses related to the areas of necrosis ranged from 13 to 135Gy. In 2 cases necrosis was situated at the boundaries of the radiation field. Imaging follow-up showed complete (n=3) or incomplete remission (n=1), lesion progression (n=11), cerebral atrophy (n=5) and stability (n=7).

CONCLUSION

MRI is useful to diagnose cerebral necrosis. New technologies may reduce the incidence of this complication.

Full dose reirradiation combined with chemotherapy after salvage surgery in head and neck carcinoma

BACKGROUND

The purpose of this study was to analyze the tolerance and efficacy of full dose reirradiation combined with chemotherapy in patients with head and neck carcinoma (HNC) with a high risk of recurrence after salvage surgery.

METHODS

Between 1991 and 1996, 25 patients having a recurrence or a second primary tumor in a previously irradiated area (> 45 grays [Gy]) were entered in this prospective study. All of them received salvage surgery and had a positive surgical margin and/or lymph node involvement with capsular rupture (N+R+). Adjuvant radiochemotherapy was given, delivering 60 Gy per 30 fractions with concomitant hydroxyurea and 5-fluorouracil. The median total cumulative dose of the 2 irradiations was 118 Gy. The median follow-up after the second irradiation was 66 months.

RESULTS

During the reirradiation course, Grade 3 and 4 mucositis were observed in 40% and 12%, respectively. Analysis of late effects (> 6 months after reirradiation) showed that 16% of the patients had osteoradionecrosis and 40% had Grade 2-3 cervical fibrosis (Radiation Therapy Oncology Group scoring system). The patterns of failure were as follows: local only (n = 9), lymph node only (n = 2), local and lymph node only (n = 1), and metastatic (n = 4). The 4-year survival rate after reirradiation was 43% (95% confidence interval, 25-62).

CONCLUSIONS

Full dose reirradiation combined with chemotherapy after salvage surgery in high risk patients with HNC was feasible with an "acceptable" toxicity and led to a relatively good 5-year survival rate. These results prompted the authors to initiate a multicentric randomized trial that is ongoing (GETTEC-GORTEC 99-01) to evaluate the benefit of adjuvant radiochemotherapy in these types of patients.

Surgical management of posterior pharyngeal wall carcinomas: functional and oncologic results

BACKGROUND

The optimal primary treatment for posterior pharyngeal wall tumors remains controversial.

METHODS

To assess the relevance of surgical treatment from a functional and oncologic point of view, we reviewed the cases of 77 patients surgically treated between 1984 and 1995. Among them 23 had been previously irradiated. Fifty-five patients underwent a conservative surgery (CS) sparing the larynx; 19 direct closures, 6 reconstructions of the posterior wall with a thoracic myocutaneous flap, 15 with a platysma flap, and 15 with a free forearm flap were performed. Twenty-two patients underwent radical surgery (RS). All previously untreated patients had postoperative radiotherapy. The functional assessment concerned the CS group. Oncologic results, especially local control and survival were studied for the whole group.

RESULTS

Of the 55 patients who underwent CS, 53 (96%) had their canula and 49 (89%) their feeding tube removed. At 1 year, in the platysma and free forearm groups, 21 of the 24 assessable patients were back to exclusive oral intake. For patients treated by primary surgery followed by radiotherapy, the rate of local failure was 11% (18% for tumors greater than 4 cm), and the 5-year survival rate was 35%. For patients who had previous radiotherapy, the rates were, respectively, 52% and 16%.

CONCLUSION

The satisfactory functional results, caused by the improvement of reconstructive procedures, allow conservative surgery even in the case of large tumors. Oncologic results, especially local control, suggest that primary surgery followed by radiotherapy is effective for the treatment of posterior wall cancer. The oncologic results of surgery in a previously irradiated area are poor, and CS is not recommended in these cases.

Results of lymphadenectomy for obvious lateroaortic lymph node metastases from colorectal primaries

BACKGROUND/AIMS

To analyze the results of surgery for macroscopically or radiologically obvious (i.e., easily detectable by computed tomography scan or by palpation) synchronous or metachronous lateroaortic lymph node metastases from colorectal primaries.

METHODOLOGY

Thirty-one highly selected patients who underwent a lateroaortic lymphadenectomy for obvious lateroaortic lymph node metastases from January 1989 to January 1999 were analyzed retrospectively. An associated metastatic lesion was present in 68% of the cases before or concomitantly with the lateroaortic lymph node metastases. Ten lateroaortic lymph node metastases were synchronous with the primary, and 21 were metachronous. Decision for lymphadenectomy was taken after a multidisciplinary meeting and a period of observation. Median follow-up after lymphadenectomy was 24.2 months (range: 6-120). All the patients received at least two systemic lines of chemotherapy before or after the lateroaortic lymphadenectomy.

RESULTS

There was no postoperative mortality. Resection was macroscopically complete (R0-1 of UICC) in 26 cases (84%). Twenty-six (83.8%) patients developed recurrent lesions or had progressive residual disease. The most frequent first site of recurrence was intrathoracic (54.8%) for the entire series, except for the subgroup of isolated lateroaortic lymph node metastases in which recurrent lesions were mainly lateroaortic. Three-year global and disease-free survival rates were, respectively, 39% and 9.6%. No significant difference was noted in survival between lateroaortic lymph node metastases that were synchronous or metachronous with the primary. However, the most important prognostic factor was the presence of associated metastases. Indeed 3-year survival attained 30% when lateroaortic lymph node metastases were isolated but 0% when lateroaortic lymph node metastases were associated with another metastatic site (P = 0.006).

CONCLUSIONS

Obvious lateroaortic lymph node metastasis is rarely isolated. However, when it is isolated, in selected cases (objective response to systemic chemotherapy, good general status), resection can be beneficial whatever its synchronous or metachronous appearance.

Radiotherapy in head and neck cancer in the elderly: a challenge

Elderly patients represent the most rapidly growing subgroup of the patient population in France and in the majority of industrialized countries. The effect of age in terms of the prognosis and response to treatment remains unclear. The management strategy (curative versus palliative) for head and neck cancer in the elderly has given vent to divergent opinions and controversies in several respects (the type and quality of treatment, quality of life and economic consequences). This review only focuses on the radiotherapy schedule and head and neck cancers. We compare aged patients with head and neck cancer to younger patients in terms of clinical features, tumor biology, type of treatment, side effects and response. We conclude that if the patient is in a good general condition following a complete evaluation of the cancer, physicians should propose curative treatment with radiotherapy because retrospective trials demonstrate that response in older patients when treated aggressively is comparable to that of younger patients. However, specific trials concerning aged patients with head and neck cancer, quality of life and radiotherapy are warranted.

A randomized study of very accelerated radiotherapy with and without amifostine in head and neck squamous cell carcinoma

PURPOSE

The aim of this study was to assess whether amifostine could minimize acute mucositis induced by a very accelerated irradiation regimen in patients with advanced head and neck squamous cell carcinoma (HNSCC).

METHODS AND MATERIALS

Between May 1996 and February 1998, 26 patients with an inoperable nonmetastatic Stage IV HNSCC were entered in this study. The treatment consisted of very accelerated radiotherapy given 64 Gy in 3.5 weeks. The patients were randomized to receive or not 150 mg/m(2), amifostine (Ethyol, U.S. Bioscience) 15-30 min prior to each radiation session.

RESULTS

Of the 13 patients who received amifostine, definitive interruption of amifostine occurred in 5 cases (38%), due to tolerance problems (vomiting, liver enzyme elevation, generalized erythema). The distribution of Grade 4 mucositis (WHO) was 1 case versus 8 cases, with and without amifostine, respectively. The mean duration of "at least Grade 3" mucositis (WHO) was 25.1 days versus 49.2 days with and without amifostine (p = 0.03). In the amifostine group, 11/13 of the patients required a feeding tube (nasogastric tube or medical gastrostomy), because of acute mucositis, whereas in the control group a feeding tube was necessary in all cases. The mean duration of the use of this feeding tube was 1 month versus 2.5 months with and without amifostine respectively (p < 0.01). Local-regional control was not different between both arms with a median follow-up of 15 months.

CONCLUSION

Despite the limited number of patients, this pilot randomized study suggests that amifostine was able to markedly reduce the severity and duration of mucositis induced by very accelerated radiotherapy. However, the tolerance of this twice daily amifostine schedule was relatively poor.

[5-fluorouracile and cisplatinum combination chemotherapy for metastatic squamous-cell anal cancer]

Anal cancers (AC) represent rare gastrointestinal tumors and there are only a few studies dealing with the treatment of AC at the metastatic stage. We report here the results of one chemotherapy regimen based on the experience of the Gustave-Roussy Institute. Between 1985 and 1996, 19 patients: 3 males, 16 females, have been treated with a combination of 5-fluorouracil (5FU) and cisplatinum (CDDP) (FUP regimen). Their median age was 58, their performance status (WHO grade: G) was G0-1 in 68% and G2 in 32% of the cases. Metastasis were synchronous in 6 cases and metachronous in 13 cases. Metastatic sites were the liver (10 cases), the lymph nodes 11 cases (paraaortic 5, iliac 4 and inguinal 2) and pulmonary in 3 cases; in 9 cases the lymph nodes metastasis were isolated, in 7 cases the liver metastasis were isolated. One patient received FUP as an adjuvant treatment has been only considered for toxicity and survival. The FUP regimen combined an IV 5FU continuous infusion (1 g/m2/d (5 days) and a short infusion of CDDP (100 mg/m2) on day 2, every 4 weeks: 10 patients received further local treatment. According to WHO criteria, 18 patients were evaluable for the efficacy and 19 for the tolerance. The median number of cycles was 4. The response rate was 66% (standard error : 22%) with 1 complete response and 11 partial response; there were also 4 stabilisations and 2 progressions. Toxicity rate was neutropenia grade (G) 3-4 in 13% of the patients without febrile neutropenia, G3 nausea in 30%, no G2 or 3 mucositis or diarrhoea, and 2 patients experienced a nephrotoxicity G1-2. The actuarial survival was 62.2% at 1 year and 32.2% at 5 years and the median survival was 34.5 months. Three patients are still alive at 4, 5 and 7 years and benefited from additional local treatment (the patient treated with adjuvant chemotherapy after hepatic resection and 2 patients treated after response to the FUP regimen, by surgery or radiotherapy). The FUP combination gave a high response rate with an acceptable toxicity in patients with metastatic anal cancer. Combined with local treatment it does allow prolonged survivals for some patients.

[Total pelvic exenteration and rectal cancer. Apropos of 20 cases]

STUDY AIM

The report of a series of 20 patients with the aim of trying to specify the implications of pelvic exenteration for rectal cancer.

PATIENTS AND METHODS

From 1986 to 1996, 20 total pelvic exenterations were performed for rectal adenocarcinoma. This retrospective study included locally extended carcinomas (n = 10), and recurrences (n = 10) after anterior resection (n = 7), and after abdominoperineal resection (n = 3). The subjects included 13 men and seven women with a mean age of 54 years (34-74 years). Complaints were major and serious: pain (n = 20), rectal syndrome (n = 17), recto-vesical fistula (n = 5) recto-vaginal fistula (n = 5), urinary infection (n = 13), and hematuria (n = 6). Preoperative radiotherapy was performed in 11 patients and preoperative radio chemotherapy in six. The surgical procedure included a total pelvic exenteration with perinectomy in 12 patients, and a total pelvic exenteration with preservation of levator ani and perineum in eight, associated in two cases with a partial resection of the sacrum, and in two other cases with partial hepatectomy for a single liver metastasis. Urinary diversion was a trans ileal ureterostomy in 17 patients and a direct double ureterostomy in three.

RESULTS

The mean duration of surgery was 6 h. The mean preoperative blood loss was 1,200 L. Nine patients received blood transfusion. There was no postoperative mortality but in contrast, the morbidity rate was high with mainly urinary and digestive complications, pelvic sepsis and thromboembolic complications. After pathological examination, tumoral resections were classified R0 in 19 cases, and R1 in one. All tumors were T4 with tumoral invasion of the bladder (n = 15), prostate (n = 6), seminal vesicles (n = 4), ureter (n = 3), vagina (n = 7), urethra (n = 1), and sacrum (n = 1). Lymph node involvement was present in four patients. The 3 and 5 year actuarial survival rate was respectively 47 and 18%. Thirteen patients died of their cancer, nine from metastases, and four from local recurrence with a mean survival of 29 and 32 months respectively. Seven patients were alive at the time of this study, six without actual recurrence.

CONCLUSIONS

In spite of its aggressive aspect, total pelvic exenteration seems justified in rectal carcinoma when extended to the urinary tract, when it causes major functional disorders, when there are no detectable metastases, and when the tumor has no posterior or lateral fixation. Local tumoral evolution can usually be controlled by pelvic exenteration but prolongation of survival is not demonstrated.

Full-dose reirradiation for unresectable head and neck carcinoma: experience at the Gustave-Roussy Institute in a series of 169 patients

PURPOSE

To review our experience using full-dose external reirradiation given with a curative intent for patients with unresectable head and neck carcinoma (HNC).

PATIENTS AND METHODS

Between January 1980 and December 1996, 169 patients who presented with unresectable nonmetastatic HNC in a previously irradiated area were included in this series. The median time between the first and the second irradiation was 33 months. Reirradiation protocols were as follows: radiotherapy alone (65 Gy over 6.5 weeks at 2 Gy/d), 27 patients; Vokes protocol, ie, five to six cycles of radiotherapy (median total dose, 60 Gy; 2 Gy/d) with simultaneous fluorouracil (5-FU) and hydroxyurea, 106 patients; and bifractionated radiotherapy (median total dose, 60 Gy; 2 x 1.5 Gy/d) with concomitant mitomycin, 5-FU, and cisplatin, 36 patients. The median cumulative dose of the two irradiations was 120 Gy. Eighty-five percent of the tumors were squamous cell carcinoma, 14% undifferentiated carcinoma of nasopharyngeal type, and 1% adenocarcinoma. Forty-four percent were local recurrences, 23% nodal recurrences, 14% both local and nodal, and 19% second primary tumors.

RESULTS

Mucositis grade 3 (World Health Organization [WHO]) was found in 32% and grade 4 in 14% of cases. Four patients presented with neutropenia or thrombocytopenia (grade 3 or 4 WHO). Late toxicities (> 6 months) were as follows: cervical fibrosis (grade 2 to 3 Radiation Therapy Oncology Group [RTOG]), 41%; mucosal necrosis, 21%; osteoradionecrosis, 8%; and trismus, 30%. Five patients died of carotid hemorrhage, apparently in complete remission. Six months after the onset of reirradiation, 37% of patients were in complete response. Patterns of failure were local only (53%), nodal only (20%), metastatic only (7%), and multiple (20%). Median follow-up time was 70 months. Overall survival rate (Kaplan-Meier) was 21% (95% confidence interval [CI], 15% to 29%) at 2 years and 9% (95% CI, 5% to 16%) at 5 years. Median survival time was 10 months for the entire population. Thirteen patients, of whom 12 were treated with the Vokes protocol, were long-term disease-free survivors. In a multivariate analysis, the volume of the second irradiation was the only factor significantly associated with the risk of death: relative risk=1.8 (95% CI, 1.13 to 5.7) (P=.01).

CONCLUSION

Full-dose reirradiation combined with chemotherapy was feasible in patients with inoperable HNC. The incidence and severity of late toxicity was markedly increased in comparison to that observed after the first irradiation. Median survival was better than that generally obtained using palliative chemotherapy alone. A small proportion of patients were long-term disease-free survivors.

[Importance of a multidisciplinary approach to metastatic cancer of the rectum]

Management of rectal cancers with synchronous metastasis is difficult. We evaluated in 23 patients a combination of pelvic radiotherapy at the dose of 45 Gy in 5 weeks and 25 fractions with chemotherapy by 5-fluorouracil (350 mg/m2/day) and folinic acid (20 mg/m2/day) for 5 days at the time of the first and the fifth week of the irradiation. Surgery was indicated firstly in cases of stricture or secondarily for resection of the primary location and, when possible, of the metastasis. General state of health of the patients improved in 35%, symptomatology in 86% and comfort in 72% of the cases. Response rates for the primary tumor were 41% of partial response and 50% of stable disease. For the metastatic lesions, they were 9% and 59% respectively. Sixty-one per cent of patients were secondarily operated with resection of the primary tumor in 12 cases and of hepatic metastases in 2 cases. The median survival and the median survival without progression were respectively 13 and 9 months. Radiochemotherapy combination as the first treatment was beneficial in 4/5 of the patients presenting a rectal cancer with synchronous metastasis and allowed us to select those that would secondarily benefit from a surgical resection.

Variations in tumour oxygen tension (pO2) during accelerated radiotherapy of head and neck carcinoma

The study was performed to assess the effect of accelerated radiotherapy on oxygenation of primary tumours and metastatic nodes in patients with advanced head and neck tumours. In 14 patients with head and neck tumour, oxygen tension (pO2) was evaluated in normal tissues and tumours (primary tumour or metastatic neck node) before (0 Gy) and after 2 weeks (32 Gy) of accelerated radiotherapy (70 Gy in 3.5 weeks, with three daily fractions). Radiotherapy was combined with carbogen breathing in 5 patients. pO2 was measured using a polarographic technique. For pooled normal tissues, median pO2 was 38 mmHg before treatment and 46 mmHg after 2 weeks. For tumours, very low values (< 2 mmHg) represented 20% of the recorded values before treatment and 10% after 2 weeks. The relative increase in tumour oxygenation was more pronounced for primary tumours (median pO2 12 mmHg before treatment versus 26 mmHg after 2 weeks, P < 0.05) than for metastatic nodes (respectively, 20 and 27 mmHg P = 0.1). For the 5 patients who breathed carbogen during accelerated radiotherapy, the median pO2 was 44 mmHg at 2 weeks, compared with 13.5 mmHg before treatment (P = 0.05). Very low pO2 values, corresponding to tumour hypoxia, were found in the tumours (primary and metastatic neck nodes) prior to accelerated treatment. During the first 2 weeks of accelerated treatment, an increase in median pO2 was found in nine of the 14 tumours, together with a decrease in the frequency of very low values.

Simultaneous high-dose external irradiation and daily cisplatin in unresectable, non-metastatic adenocarcinoma of the pancreas: a phase I-II study

BACKGROUND AND PURPOSE

Clinical trials have demonstrated that high dose radiation therapy and daily cisplatin (CDDP) could increase local control and survival in carcinoma from various sites. The present phase I-II study has combined high dose radiation therapy and daily CDDP at escalating dosages.

METHODS

From August 1994 to December 1995, 23 patients with non-resectable carcinoma of the pancreas were enrolled in a phase I-II multicentric, pilot study to test the toxicity and the effectiveness of high dose radiotherapy and daily cisplatin (CDDP) at escalating dosages. A dose of 6 mg/sqm/day of CDDP was selected for the phase II step since no grade IV toxicity occurred in any patient in the phase I step.

RESULTS

Toxicity was considered fairly acceptable. At the time of analysis, the 23 patients who entered the study had clear evidence of evolutive disease either locally or distantly in the liver. It is suggested that high dose radiotherapy (60 Gy continuously) and daily CDDP have little effect on local control of the tumor and survival, and only a moderate effect on pain.

CONCLUSIONS

In unresectable, apparently non-metastatic cancers of the pancreas, there is an urgent need for new agents or new combinations of agents to be tested.

Accelerated fractionation (AF) compared to conventional fractionation (CF) improves loco-regional control in the radiotherapy of advanced head and neck cancers: results of the EORTC 22851 randomized trial

BACKGROUND AND PURPOSE

A 5 week-hyperfractionated and accelerated radiotherapy regimen without reduction of the total dose was developed to fight tumour repopulation during treatment and tumour hypoxia. The purpose of the study was to try to improve loco-regional control in high risk head and neck carcinoma treated with curative radiotherapy.

METHODS AND MATERIALS

From 1985 to 1995, a randomised controlled trial of the EORTC Cooperative Group of Radiotherapy (EORTC 22851) compared the experimental regimen (72 Gy/45 fractions/5 weeks) to standard fractionation and overall treatment time (70 Gy/35 fractions/7 weeks) in T2, T3 and T4 head and neck cancers (hypopharynx excluded). The end-point criteria were local and loco-regional control, overall and disease-free survival, and acute and late toxicities. Five hundred twelve patients were accrued.

RESULTS

Patients in the AF (accelerated fractionation) arm did significantly better with regard to loco-regional control (P = 0.02) resulting at 5 years in a 13% gain (95% CI 3-23% gain) in loco-regional control over the CF (conventional fractionation) arm. This improvement is of larger magnitude in patients with poorer prognosis (N2-3 any T, T4 any N) than in patients with more favourable stage. Multivariate analysis confirmed AF as an independent prognostic factor of good prognosis for loco-regional control (P = 0.03). Specific survival shows a trend (P = 0.06) in favour of the AF arm. ACUTE AND LATE TOXICITIES: Acute and late toxicity were increased in the AF arm. Late severe functional irradiation damage occurred in 14% of patients of the AF arm versus 4% in the CF arm. Two cases of radiation-induced myelitis occurred after doses of 42 and 48 Gy to the spinal cord.

CONCLUSIONS

This trial shows that accelerated radiotherapy improves loco-regional control in head and neck squamous cell carcinomas. A less toxic scheme should, however, be investigated and documented before using accelerated radiotherapy as a standard regimen of curative radiotherapy for head and neck cancers.

Preliminary results of a phase II study of high-dose radiation therapy and neoadjuvant plus concomitant 5-fluorouracil with CDDP chemotherapy for patients with anal canal cancer: a French cooperative study

BACKGROUND

Chemotherapy (5-fluorouracil-mitomycin C) concomitant with radiotherapy (RT) increases local control and colostomy-free survival in advanced anal canal carcinomas (ACC). The purpose of this prospective trial was to analyse the toxicity of and response to an induction chemotherapy combining 5-fluorouracil (5-FU) and CDDP administered concomitantly with irradiation.

PATIENTS AND METHODS

Thirty patients (24 F/6 M, mean age 60, range 38-74) with an advanced ACC > 40 mm and/or with node involvement were prospectively treated (1 T1, 16 T2, 8 T3, 5 T4, 10 N1, 1 N2, 8 N3) from November 1994 to January 1996. Two induction and two concomitant cycles of 5-FU (800 mg/ m2 D1-4 infusion) and CDDP (80 mg/i.v./m2 at D1) were delivered. RT consisted of 45 Gy (1.8 Gy/fr, 5 fr/w) on pelvis +/- inguinal nodes or 30 Gy (3 Gy/fr, 4 fr/w) by direct perineal field. A boost (15-20 Gy) was delivered six weeks later.

RESULTS

TOXICITY

one patient died of a pulmonary embolism on D4. The remaining 29 received the entire treatment, with reduced 5-FU doses in 11 patients because of acute toxicity. The RT boost was delayed for one patient (aplasia). In 109 cycles, 3 grade 4 and 17 grade 3 toxicities were observed; there were no toxic deaths. Tumor response: the complete response (CR) and partial response (PR) rates were, respectively, 11% and 61% after induction chemotherapy, 59% and 31% after concomitant radiochemotherapy and 96% and 0% two months after completion of the treatment. No tumor progression was observed.

CONCLUSION

the treatment was well tolerated and there was good compliance. After induction chemotherapy, most of the patients were in PR, with some even in CR. After completion of the treatment all but one were in CR. The tumor response and the long term results of 50 patients will be analysed before initiation of a randomised trial is considered.

Status of accelerated fractionation radiotherapy in head and neck squamous cell carcinomas

Considerable interest has been shown in recent years about hyperfractionated and accelerated radiation therapy for head and neck squamous cell carcinomas. The first randomized trial showing an advantage for hyperfractionation in terms of tumor control was the European Organization for Research and Treatment of Cancer 22791 trial. More recently, accelerated radiotherapy has been tested in many studies showing that high total doses of radiation could be delivered in overall treatment time shorter than conventional radiation therapy. The benefit of accelerated radiation therapy has been reported in some recently completed randomized trials, which suggests that rapid repopulation of surviving tumor cells during radiation therapy is a major determinant to obtain cure in this type of cancer.

Abdominoperineal resection combined with pre- and postoperative radiation therapy in the treatment of low-lying rectal carcinoma

PURPOSE

A series of patients with rectal carcinoma irradiated by a sandwich technique combined with surgery is retrospectively analyzed.

METHODS AND MATERIALS

From 1978 to 1991, 155 patients with low or mid rectal carcinoma received abdominoperineal resection combined with a preoperative irradiation regimen of 35 Gy delivered in 14 fractions of 2.5 Gy each over a period of 3.5 weeks. The dose was increased to 45 Gy in the case of tumor fixation. According to histopathological findings, this irradiation was complemented in 87 cases by a postoperative dose of 25 Gy delivered in 10 fractions, for a total dose of 60 Gy delivered in the posterior pelvis.

RESULTS

Five-year survival was 66.8% for the entire population. The 5-year actuarial local control rate was 77.6%. Carcinologic results and toxicity were analyzed according to the pathological findings and the modalities of radiation therapy.

CONCLUSIONS

The postoperative boost after a preoperative moderate dose of irradiation seems to have no utility. Thus, this sandwich technique is not recommended.

Results of a phase II trial of epirubicin and cisplatin (EP) before and after irradiation and 5-fluorouracil in locally advanced pancreatic cancer: an EORTC GITCCG study

The objective of the present study was to define the role of chemotherapy, in the form of the EP regimen, consisting of epirubicin (E) and cisplatin (P) in addition to irradiation in combination with 5-fluorouracil (5-FU) for treatment of pancreatic cancer. 53 eligible patients with histologically or cytologically proven locally advanced pancreatic cancer were treated with three cycles of E 60 mg/m2 (if this dose was well tolerated then the dose of E was increased by 10 mg/m2 in the next cycle; 80 mg/m2 was the maximum dose for the following cycles) and P 100 mg/m2 once every 3 weeks, followed after 4 weeks by a split course of irradiation of 40 Gy with 5-FU 500 mg/m2 on each of the first 3 days of each 20 Gy treatment segment. This was followed by another three cycles of EP in patients who achieved stable disease (SD) or a better response after the first three cycles. The treatment given with standard anti-emetics was moderately tolerated. The chemotherapy related toxicity consisted mainly of myelosuppression and the chemoradiotherapy related toxicity of gastrointestinal side-effects. However, due to the long duration of treatment which made the whole treatment difficult to endure, only 18/53 (34%) actually completed the full treatment regimen. Responses were evaluated after the first three cycles and 4 weeks after the completion of the treatment by serial CT-scans using standard criteria. The results in 53 evaluable patients after the first three cycles of EP were as follows: 1 patient achieved a clinical complete response (CR), 7 a partial response (PR) (CR + PR: 15%; 95% confidence interval (CI): 11-33%), 36 patients (68%) had stable disease (SD) and 6 patients progressive disease (PD). There was 1 early PD, 1 toxic death and 1 patient could not be evaluated. The response at the end of the treatment was 3 CR, 11 PR (CR + PR: 14/53 (26%); 95% CI: 15-40%), 30 SD and 6 PD. The median time to progression was 8.9 months and the median duration of response 13.1 months. The median survival of all treated patients was 10.8 months (range 7 days to 41.5 months), of responders 15.1 months and, of the patients with SD 10.3 months. These results are comparable to other combined modality regimens reported in the literature for locally advanced disease. The addition of the systemic treatment with E and P offers no additional advantage to combined modality treatment alone.

[Value of endorectal ultrasonography in the treatment of rectal tumors]

OBJECTIVES

To determine the diagnostic accuracy of endosonography and to appreciate its influence on the therapeutic strategy.

METHODS

Sixty-two patients referred to the gastroenterology unit between April 1990 and February 1995 for a rectal tumor. Thirty-two patients did not receive any preoperative treatment (group A) and 30 were treated by radiotherapy or chemoradiotherapy before surgery (group B). Transrectal ultrasonography was performed with a Bruel and Kjaer device.

RESULTS

Diagnostic accuracy for parietal infiltration was 84% for the entire series, 94% for group A and 73% for group B. Diagnostic accuracy of lymph node invasion was 71% for the entire series, 81% and 60% for groups A and B, respectively. It is highly probable that a histopathologic down-staging due to preoperative treatment explained the results in the group B. Using a pragmatic approach which combined the results for parietal infiltration and for lymph node invasion, transrectal ultrasonography would have correctly selected 20 among the 25 patients who could have been treated by local excision. The use of this same pragmatic approach in patients with high risk of local recurrence enabled correct selection of 26 among the 32 exposed patients.

CONCLUSION

We conclude that transrectal ultrasonography: 1. is a reliable technique for the pretherapeutic staging of rectal cancer, especially for the assessment of parietal infiltration. Progress is needed for the diagnosis of lymph node invasion; 2. selects well the patients who can be treated by local excision; 3. is a reliable technique for the selection of patients who need preoperative treatment.

[Accelerated radiotherapy: initial results in a series of locally very advanced carcinomas of the upper respiratory and digestive tracts]

From 1992 to 1993, 46 patients with very locally advanced (74% T4) head and neck carcinomas and extensive cervical involvement (82% N2-3) were treated at the Institute Gustave Roussy with a very accelerated radiotherapy regimen: 62 Gy in three weeks with two daily 1.75 Gy fractions. Early mucosal reactions were severe but manageable in this population of patients with frequent alteration of initial performance status. Nearly every patient experienced a grade 3 or 4 (WHO) mucositis and 80% required tube feeding. Follow-up is not sufficient to draw firm conclusion about late reactions but they do not seem different from those induced by conventional radiotherapy. The overall 2-year survival rate of 49.4% and loco-regional control rate of 67% seem superior to the results of conventional radiotherapy for such advanced tumors. These results have led to a multi-center randomized controlled trial comparing this regimen of accelerated radiotherapy with conventional fractionated radiotherapy.

Very accelerated radiation therapy: preliminary results in locally unresectable head and neck carcinomas

PURPOSE

To report preliminary results of a very accelerated radiation therapy Phase I/II trial in locally advanced head and squamous cell carcinomas (HNSCC).

METHODS AND MATERIALS

Between 01/92 and 06/93, 35 patients with an unresectable HNSCC were entered in this study. Thirty-two (91%) had Stage IV, and 3 had Stage III disease. The mean nodal diameter, in patients with clinically involved nodes (83%), was 6.3 cm. The median Karnovsky performance status was 70. The treatment consisted of a twice daily schedule (BID) giving 62 Gy in 20 days.

RESULTS

In all cases, confluent mucositis was observed, which started about day 15 and resolved within 6 to 10 weeks. Eighty percent of patients had enteral nutritional support. The nasogastric tube or gastrostomy was maintained in these patients for a mean duration of 51.8 days. Eighteen patients (53%) were hospitalized during the course of treatment due to a poor medical status or because they lived far from the center (mean 25 days). Nineteen patients (56%) (some of whom were initially in-patients) were hospitalized posttreatment for toxicity (mean 13 days). Five patients (15%) were never hospitalized. During the follow-up period, 12 local and/or regional failures were observed. The actuarial 18-month loco-regional control rate was 59% (95% confidence interval, 45-73%).

CONCLUSIONS

The dramatic shortening of radiation therapy compared to conventional schedules in our series of very advanced HNSCC resulted in: (a) severe acute mucosal toxicity, which was manageable but required intensive nutritional support in all cases; and (b) high loco-regional response rates, strongly suggesting that the time factor is likely to be critical for tumor control in this type of cancer.

Lymph node prognostic factors in head and neck squamous cell carcinomas

BACKGROUND

This retrospective study included 914 patients who underwent a lymph node dissection at our institute between 1980 and 1985. The primary tumor sites were oral cavity, 287; hypopharynx, 249; larynx, 247; and oropharynx, 131.

PATIENTS AND METHODS

On the basis of anatomic considerations, the sentinel nodes for well-lateralized oral cavity tumors were defined as homolateral levels I, II, and III; for oropharyngeal, hypopharyngeal, and laryngeal tumors, the sentinel nodes were defined as levels II and III. We took into account the ipsilateral side of the neck for well-lateralized tumors, and both sides for medium or large tumors. For clinically positive nodes of more than 3 cm, a radical neck dissection was performed. Other patients underwent a selective neck dissection on sentinel nodes, with immediate pathologic evaluation. Modified radical neck dissections with contralateral selective dissection were performed when frozen sections were positive. Patients with positive nodes were given postoperative radiotherapy.

RESULTS

The prognostic factors studied, using the Cox survival model adjusted on the primary tumor site, surprisingly showed a nonsignificant value for extracapsular spread (P = 0.09), and a significant value for the number of positive nodes (P < 0.001) and for the positive node in or out of the sentinel node sites (P < 0.001). Although the node location factor can be used instead of positive node in or out of the sentinel node site, it has a less significant prognostic value.

CONCLUSIONS

The most significant prognostic factors are the site of the positive node in or out of the sentinel node and the number of positive nodes; and a more accurate approach can be obtained by combining both factors. Node location in the upper or lower neck remains a substitute prognostic factor for the site of the positive node in or out of the sentinel node.

Sarcomas of nasal cavity and paranasal sinuses: chondrosarcoma, osteosarcoma and fibrosarcoma

Forty-two patients were treated for sarcoma of the nasal cavity and paranasal sinuses at the Institut Gustave Roussy, Paris, between 1960 and 1993. Twelve patients had chondrosarcoma (CS), 14 had osteosarcoma (OS) and 16 had fibrosarcoma (FS). Ten patients had grade I, six grade II and 26 grade III tumours. All but 10 patients had surgery for the primary tumour. A significantly increased risk of local failure was associated with the male sex (p < 0.01), grade III tumours (p < 0.02) and patients excluded from surgery (p < 0.04). The overall incidence of local and distant failure was 76 and 12 per cent respectively. Overall survival was 28 per cent at three years and 23 per cent at five years. Eight patients (20 per cent) were alive more than 10 years later. The factors significantly influencing survival were sex (p < 0.01), grade (p < 0.05) and local failure (p < 0.01).

Accelerated radiation therapy in the treatment of very advanced and inoperable head and neck cancers

PURPOSE

A Phase II trial testing a continuous and accelerated regimen of radiotherapy in very advanced head and neck cancers.

METHODS AND MATERIALS

From 1988 to 1990, 47 patients with very advanced and inoperable tumors (38/47 T4) of the oral cavity and the oropharynx were submitted to a continuous and accelerated regimen of hyperfractionated radiation therapy: three daily fractions of 0.9 Gy were delivered 5 days-a-week, up to the 70 Gy total dose, reducing the overall treatment time to 5.5 weeks.

RESULTS

Immediate tolerance was good: only 56% of the patients experienced a Grade 3 mucositis, and the mean weight loss was 2 kg. The 2-year survival rate was 24.6%. The 2-year local control rate was 42.6%, which compares favorably with the 20% local control rate obtained in a historical control group of patients treated with another hyperfractionated regimen between 1978 and 1986. Mid- and long-term tolerance were excellent, no late complication or sequellae were observed which was also quite different from our previous experience.

CONCLUSION

These results suggest an improvement of the local control and the therapeutic ratio with acceleration of radiotherapy in head and neck cancers.

Tumor oxygenation after 1) carbogen and/or perflubron emulsion administration in tumor xenografts 2) carbogen administration in patients

This study examines the changes in tumor pO2 distribution assessed by polarography (KIMOC 6650, Eppendorf) in 1) two human tumor xenografts after carbogen inhalation with or without a perflubron (perfluorooctylbromide) emulsion (Oxygent, Alliance Pharmaceutical corp.) and in 2) human head and neck carcinomas after carbogen inhalation. Mice bearing HRT18 or NA11+ tumors were restrained and their body temperature was kept constant. Perflubron emulsion (4 ml/kg) was injected i.v. in the mice. In patients, oxygenation of the head and neck metastatic lymph nodes was assessed before and/or during carbogen exposure. The distribution of pO2 values shifted upwards during carbogen exposure in both animals and patients while the proportion of low pO2 values decreased. The maximal effect was obtained with patients after 1 to 6 minutes of carbogen exposure, but 4 patients still maintained very low pO2s. Carbogen plus 4 ml/kg perflubron emulsion was more efficient than carbogen alone for increasing hypoxic tumor pO2 in animals. If the animals data could be extrapolated to humans, then the effect of carbogen on tumor oxygenation should be increased by perflubron emulsion administration.

Changes in the oxygenation of head and neck tumors during carbogen breathing

The oxygenation of head and neck tumors and changes during carbogen breathing were assessed in 20 patients. The median oxygen tension (pO2) for each patient was lower in tumors before breathing carbogen than in normal tissues. The median pooled pO2 of all the tumors was 20 mmHg; for normal tissue it was 60 mmHg. Low values (below 10 mmHg) were found in 4 patients for the normal tissue and in 18 patients for tumors. During carbogen breathing, the median (61 mmHg) pO2 readings for all tumors was higher than that recorded before carbogen breathing. The frequency of low (< 10 mmHg) pO2 values decreased with carbogen breathing in 11 patients; only 4 patients still exhibited very low values (< 2 mmHg). Maximal effect was obtained within 1-6 min of gas exposure. The pO2 stayed high under carbogen breathing in 15 out of 16 patients. Return to pre-carbogen levels of oxygenation occurred in 1 min after the end of gas exposure. These data suggest that carbogen breathing increases tumor oxygenation as assessed by polarography. The breathing time appears to be important for therapeutical use and should to be taken into consideration.

Oxygenation of head and neck tumors

BACKGROUND

Tumor hypoxia could play a role in the response to radiation therapy. Few data are available on oxygen tension (pO2) measurements in head and neck tumors.

METHODS

The KIMOC-6650 Histograph (Eppendorf, Hamburg, Germany) was used to measure the oxygenation status of normal tissues and head and neck tumors in 20 patients.

RESULTS

The median pO2 for normal tissues was 43 mmHg with very low pO2 values (2.0 mmHg or less) recorded in two patients. Low median pO2 levels (10 mmHg or less) were recorded in 2 of 5 primary tumors and in 11 of 15 metastatic lymphadenopathies, with very low values in 11 nodes. The median pO2 in tumors was lower than that of normal tissues in 12 of 15 patients with comparative measurements. Oxygen tension was recorded in three nodes after an evaluation of tissue density (by computed tomographic scanner); in two nodes, the mean and median pO2 values were lower in the hypodense areas than in isodense areas. The data for N2 and N3 nodes showed significantly more values below 2.0 mmHg as nodal size increased (P < 10(-4), by chi-square test). No systematic decrease in pO2 was recorded from the periphery to the center of the tumors.

CONCLUSIONS

Very low pO2 values, corresponding to radiobiologic hypoxia, were found in most of these tumors. The prognostic value of these pO2 measurements in regard to treatment response remains to be demonstrated.

Salvage surgery by composite resection for epidermoid carcinoma of the tonsillar region

Radiation therapy has usually been used as the primary treatment of squamous cell carcinoma of the posterior aspect of the oral cavity and the lateral aspect of the oropharyngeal walls. However, local failure occurs in a certain number of cases, depending on the initial tumor stage. One hundred thirty-four composite resections (transmaxillary buccopharyngectomies) have been performed as a salvage treatment at the Institut Gustave-Roussy, Villejuif, France, from January 1, 1976, through December 31, 1985, for local failure of epidermoid carcinomas treated initially by radiotherapy. Average time between primary irradiation and salvage surgery was 18 months. Most of the patients underwent some kind of supraomohyoid neck dissection. A myocutaneous flap was used in 18% of cases, which significantly reduced the rate of local complications. The nasogastric tube and the tracheostomy cannula were removed after a median delay of 23 days and 24 days, respectively. Early postoperative local complications occurred in 45% of cases; most of them were minor. A new locoregional recurrence occurred in approximately half of the patients and was usually fatal. Overall survival after salvage surgery was 34% at 3 years and 23% at 5 years. The only statistically significant prognostic factor was the adequacy of surgical margins.

[Choroid metastasis in a case of urothelial carcinoma metastatic from the bladder]

A 40 year old male, presented with a left choroidal metastases, 2 month after a radical cystectomy for an infiltrating transitional cell carcinoma of the bladder. This localisation was associated with disseminated metastasis which failed to respond to chemotherapy. The patient died within one month. The review of the literature confirms the poor prognosis of choroidal metastases in patients with transitional cell carcinoma of the bladder.

Radiation therapy for head and neck cancers in the elderly

Three hundred and thirty-one patients, aged more than 70 years, were treated for an upper aerodigestive tract carcinoma from 1978 to 1983. Larynx accounted for 28% of the primary sites, oropharynx for 27%, and the oral cavity for 16%. One-third of these patients had a contraindication to anesthesia. The treatment was consistent with our protocols in only half of the cases. Fifty-nine patients underwent a radiosurgical combination; 249 underwent an exclusive irradiation with a curative intent. Fifty-four patients underwent a palliative irradiation, which lead up to a "curative dose" in half of the cases. The immediate and long-term tolerance of the irradiation was good. The local control was 71% for patients treated with a curative intent and 19% for the palliatively irradiated patients. Five-year survival of the population was 33%. No significant relationship between age, general status, and the carcinologic outcome could be observed.

Osteoradionecrosis of the mandible: study of 104 cases treated by hemimandibulectomy

One hundred and four cases of osteoradionecrosis (ORN) of the mandible following irradiation of head and neck cancer are reported. Conservative management for ORN failed in all cases. Indications of hemimandibulectomy included intractable pain, severe trismus, pathological fracture, oro-cutaneous fistula and persistent exposure of bone. Surgical approach was intra-oral in 100 cases and extra-oral in four. Immediate soft tissue reconstructions were carried out in 20 per cent cases. Post-operative complications included minor sepsis (8.6 per cent), major sepsis (2.9 per cent), haemorrhage (2.9 per cent) and fistula (3.8 per cent). Major complications occurred only in patients treated exclusively by external irradiation at doses equal to or higher than 65 Gy. Relief from pain and trismus was obtained and normal swallowing was established following radical surgery.

External irradiation plus curietherapy boost in 108 base of tongue carcinomas

From 1960 to 1983, 108 patients underwent an association cobaltherapy plus curietherapy boost for a base of tongue carcinoma. This group included 18 T1 tumors, 39 T2, and 51 T3. Cobaltherapy was delivered to a dose of 45 Gy/4.5 weeks to the primary site and the neck. It was completed by an electron boost or a nodal surgery in case of initial nodal disease. Two techniques of Curietherapy were used: plastic tubes and guide-gutters. As most of these implants have been done before 1975, all the doses have been recalculated on the 85% isodose according to the Paris system. They varied from 22 to 88 Gy. The tolerance of the implantation was excellent. Five-year survival of the whole group is 26%. The local control rate is 85% for T1 tumors, 50% for T2, and 69% for T3. Despite the importance of cumulated doses, a few necrosis were observed. Considering the poor outlook of this cancer, its treatment by exclusive radiotherapy requires very high doses which can only be delivered without major sequellae or complication by a combination of cobaltherapy and curietherapy boost.

Radiation therapy in the treatment of early glottic carcinoma: the experience of Villejuif

A retrospective analysis of 197 early glottic carcinoma treated with small field irradiation to a dose of 65 Gy is presented. The 5-year survival rate was 77.3%. Thirty-eight local failures have been observed, and the 5-year local control rate was 85.7%. Suspicion of extra glottic extension was the main prognostic factor. Final local control rate, taking into account the salvage treatment, was 90% at 5 years. Excellent functional results were observed.

Exclusive radiation therapy: the treatment of early tonsillar tumors

One hundred and ninety-three T1 or T2 tumors of the tonsillar region have been treated by exclusive external irradiation between 1970 and 1982. Seventy-five percent of these tumors were classified as T2. There was no relationship between T and N stages. The nodal involvement was essentially linked to the macroscopic appearance of the tumor (superficial or nodular) and to the histology. The 5-year survival rate of the whole population was 58%. N stage and macroscopic appearance only influenced the survival. The local control was 88% for T1, 79% for T2. The main prognostic factors for local control were the histological type, with a 93% local control rate for poorly differentiated tumors versus 73% for well differentiated ones, and the macroscopic appearance, with a 83% local control rate for nodular tumors versus 75% for superficial ones. Superficial tumors spreading forward the anterior pilar have a higher local failure rate. All the patients' charts have been reviewed, and we observed a high percentage of marginal recurrences. The technique of irradiation, above all in case of a superficial tumor, must take into account the possibility of "geographic miss" and keep large safety margins.

Limited small cell lung cancer treated by combined radiotherapy and chemotherapy: evaluation of a grading system of lung fibrosis

A grading system of radiological fibrosis was defined and applied by four observers for the reading of 218 posterior-anterior chest X-rays of 78 patients. These patients with limited small cell lung cancer were treated from May 1980 to July 1983 in two consecutive alternating radiotherapy-chemotherapy schedules. Chest X-rays performed at each 6-month interval were read by each observer. A second reading was performed the day after. The analysis of results showed that in spite of some systematic variations in intra- and inter-observations, the proposed grading system had a good reproducibility. The radiological lung fibrosis score progressed between 6 and 12 months but was stable after one year of follow-up. There was no difference in the score of lung fibrosis between the two protocols which delivered a total dose of 45 and 55 Gy to the mediastinum. There was no significant correlation between the radiological changes and clinical symptoms.