Efficacy of Large Use of Combined Hypofractionated Radiotherapy in a Cohort of Anti-PD-1 Monotherapy-Treated Melanoma Patients

To assess the role of radiotherapy in anti-PD-1-treated melanoma patients, we studied retrospectively a cohort of 206 consecutive anti-PD-1 monotherapy-treated advanced melanoma patients (59% M1c/d, 50% ≥ 3 metastasis sites, 33% ECOG PS ≥ 1, 33% > 1st line, 32% elevated serum LDH) having widely (49%) received concurrent radiotherapy, with RECIST 1.1 evaluation of radiated and non-radiated lesions. Overall (OS) and progression-free (PFS) survivals were calculated using Kaplan−Meier. Radiotherapy was performed early (39 patients) or after 3 months (61 patients with confirmed anti-PD-1 failure). The first radiotherapy was hypofractionated extracranial radiotherapy to 1−2 targets (26 Gy-4 weekly sessions, 68 patients), intracranial radiosurgery (25 patients), or palliative. Globally, 67 (32.5% [95% CI: 26.1−38.9]) patients achieved complete response (CR), with 25 CR patients having been radiated. In patients failing anti-PD-1, PFS and OS from anti-PD-1 initiation were 16.8 [13.4−26.6] and 37.0 months [24.6−NA], respectively, in radiated patients, and 2.2 [1.5−2.6] and 4.3 months [2.6−7.1], respectively, in non-radiated patients (p < 0.001). Abscopal response was observed in 31.5% of evaluable patients who radiated late. No factors associated with response in radiated patients were found. No unusual adverse event was seen. High-dose radiotherapy may enhance CR rate above the 6−25% reported in anti-PD-1 monotherapy or ipilimumab + nivolumab combo studies in melanoma patients.

Breast-conserving therapy can be offered to women with prior breast augmentation

INTRODUCTION

Breast cancer in women with cosmetic breast implants is increasingly common. Over the past decade, there has been a push for mastectomy and reconstruction in these patients, based on a fear of poor aesthetic results from small breast volume, and radiation-induced capsular contracture. At the Paris Breast Centre, augmented women routinely undergo lumpectomy with whole-breast irradiation (BCT).

MATERIALS AND METHODS

A consecutive cohort of 50 augmented women, who had attempted BCT for early breast cancer at our institution between 2003 and 2018, were retrospectively identified. Post-treatment complications, oncologic outcomes, capsular contracture rates, long-term cosmetic outcomes, and patient-reported outcomes were evaluated.

RESULTS

The median follow-up was 51 months. Margins were involved in 7 women (14%); 4 of whom underwent successful re-excision, and 3 had a mastectomy, for an early mastectomy rate of 6%. There were no early complications, nor cases of early implant loss. Long-term aesthetic results were evaluated using our 5-point scale: An excellent (5), or good (4) result was obtained in 68%. Significant capsular contracture (Baker grade 3 or 4) developed in 34%, of which, 5 women underwent capsulotomy and fat grafting; 4 of 5 downstaging their Baker grade. The estimated 5-year local recurrence rate was 2.3%. Ninety-five percent of participants would recommend BCT to augmented women.

CONCLUSION

BCT is feasible and safe in augmented women with good long-term aesthetic results, and should be considered to avoid unnecessary mastectomy.

Efficacy of late concurrent hypofractionated radiotherapy in advanced melanoma patients failing anti-PD-1 monotherapy

Advanced melanoma patients who failed anti-PD-1 therapy have limited options. We analyzed a cohort of 133 advanced melanoma patients receiving anti-PD-1 monotherapy in a referral center between April 2015 and December 2017, and included the 26 patients with confirmed progressive (PD) or stable disease who received additional radiotherapy with an unmodified anti-PD-1 mAb regimen. Tumor evaluations were done on radiated and nonradiated (RECIST 1.1) lesions, with abscopal effect defined as a partial (PR) or complete response (CR) outside radiated fields. Primary endpoint was the CR + PR rate in radiated + nonradiated lesions. Secondary endpoints were progression-free survival (PFS), melanoma-specific survival (MSS) and safety. First late radiotherapy, consisting of hypofractionated radiotherapy (3-5 sessions, 20-26 Gy), standard palliative radiotherapy or brain radiosurgery was begun after a median of 6.3 months of anti-PD-1 in 23, 2 and 1 patient(s), respectively. Best response was 8 (31%) CR, 2 (8%) profound PR allowing surgical resection of remaining metastases and 16 (62%) PD. Abscopal effect was seen in 35% of patients. Median PFS and MSS since anti-PD-1 initiation was 15.2 [95% CI: 8.0 not achieved (na)] and 35.3 [95% CI: 18.5 na] months, respectively. PFS curves seemed to achieve a plateau. We discontinued anti-PD-1 therapy in 9/10 of patients with no residual evaluable disease and observed one relapse after a median of 10 months off anti-PD1-therapy. No unusual adverse event was recorded. Limitations of the study include its retrospective nature and limited size. Hypofractionated radiotherapy may enhance anti-PD1 monotherapy efficacy in patients who previously failed anti-PD-1 therapy. Controlled studies are needed.

Efficacy of hypofractionated radiotherapy (Rx) in melanoma patients who failed anti-PD-1 monotherapy: Assessing the abscopal effect

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Background: Radiotherapy (Rx) and anti-PD-1 mAb are potentially synergistic. No study has tested this combination only in pts who failed on anti-PD-1 mAb, which allows to assess the abscopal effect. We evaluated this combination in a cohort of advanced melanoma pts after failure of anti-PD-1 monotherapy. Methods: Analysis of a prospective database in a referral center searching for advanced melanoma pts with confirmed (2 CT-scans) progressive (PD) or stable (SD) disease on anti-PD-1 monotherapy, who later received concurrent Rx without modification of anti-PD-1 mAb regimen. Radiologists performed independent tumor evaluations (RECIST 1.1) every 3 m, both on radiated and non-radiated lesions, with abscopal effect defined as a partial (PR) or complete (CR) response outside radiated fields. Results: 26 pts (21 achieving PD, 5 SD, 10 pt ≥3 involved organs), mean age 70 Y, were included. Anti-PD-1 mAb was first line in 50% of pts. Rx, consisting of hypofractionnated Rx (3-5 sessions, 26 Gy), standard palliative Rx, or gamma-knife in respectively 23, 2, and 1 pts, was begun on a single site in 73% of pts or on 2 sites after a median of 5 m after beginning anti-PD-1 mAb. Median follow-up after onset of anti-PD-1 mAb was 17 (7-35) m, with 65% of pts alive at last follow-up. Best response was 7 CR (27%, including CR in 4 pts with prior PD) 1 PR, 3 SD (12%), 15 PD (58%). Abscopal effect was seen in 10 pts (38%). No correlation between the occurrence of CR and BRAF/NRAS mutation status, number of metastatic sites, presence or absence of brain metastases, and LDH level was seen. Anti-PD-1 mAb could be discontinued in 6 pts with CR, without relapse to date. No unusual adverse event was recorded. Conclusions: In pts who have previously failed on anti-PD-1 mAb, obtaining with concurrent Rx and without modifying anti-PD-1 mAb, CR or PR in 30% of pts, median OS not achieved, and abscopal effect in > 1/3 of pts is probably not due only to late efficacy of anti-PD-1 mAb but suggests a synergy with RT. Release after radiation of tumor neoantigens may stimulate immune response. Hypo-fractionated radiotherapy may enhance anti-PD1 monotherapy efficacy in melanoma pts who failed on anti-PD-1 mAb. Controlled studies are needed.

Efficacy of combined hypofractionated radiotherapy and anti-PD-1 monotherapy in patients with melanoma

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Background: Information on the role and type of radiotherapy in melanoma pts treated with anti-PD1 is limited. We report a cohort of advanced melanoma pts having received simultaneous hypofractionated radiotherapy and anti-PD-1 monotherapy. Methods: Database search in the prospective database of a referral center with standardized radiotherapy procedures for all pts having received both treatments between 1/1/15-30/6/16. Radiologists performed independent tumor evaluations (RECIST 1.1) every 3 m, both on radiated and non-radiated lesions. Results: 25 pts with inoperable AJCC stage 3-4 melanoma, mean age 60.5 Y. Anti-PD-1 monotherapy was first systemic treatment in only 40% of pts. Median follow-up after onset of anti-PD-1 therapy (83% nivolumab, 17% pembrolizumab) was 13.3 m, with 48% of pts still alive at last follow-up. Radiotherapy was performed either early (within first 3 m of PD-1 blockade) in pts with rapidly progressing symptomatic lesion(s) (60% of pts) or late ( > 3 m) in pts with slow progression or dissociated response (40% of pts). It consisted of 1 weekly radiation during 4-5 w (84% of pts), or 1 gammaknife radiation for cerebral mets (16% of pts). Median delay between onset of PD-1 blockade and radiotherapy was 1.8 m (range 0.5-11 m). For radiated lesions, rates of complete (CR), partial (PR) responses, stabilization (S) or progression (P) were 24%, 8%, 44%, and 28%, respectively. For non-radiated lesions (84% of pts), rates of CR, PR, S, and P were 29%, 19%, 19%, and 33%, respectively. Among pts radiated late for insufficient response to anti-PD-1 monotherapy, CR or PR in non-radiated lesions (i.e. abscopal response) was observed in 56% of pts. Anti-PD-1 therapy could be discontinued in 4 pts with CR, without relapse to date. No unusual adverse event was recorded. Conclusions: Hypofractionated radiotherapy may enhance anti-PD1 monotherapy efficacy in difficult-to-treat pts. Controlled studies are needed.

[Conservative treatment undifferentiated neuroendocrine tumors of the anal canal: two cases]

Undifferentiated neuroendocrine tumors are rare, and are characteristically aggressive with a poor prognosis. Most patients have metastatic disease at diagnosis, and cannot undergo curative surgical treatment. A chemotherapy regimen combining etoposide plus cisplatin is currently considered to be the reference treatment. We report two cases of poorly differentiated neuroendocrine tumors localized in the anal canal and treated by chemotherapy and radiotherapy resulting in prolonged complete local remission and preventing extended surgical excision.

Chemotherapy as initial treatment of locally advanced unresectable pancreatic cancer: a valid option?

INTRODUCTION

Radio-chemotherapy is the standard treatment for locally advanced unresectable pancreatic cancer (LAPC). Chemotherapy has been shown to be effective in the treatment of metastatic disease and we therefore evaluated its use as a first-line treatment for LAPC.

PATIENTS AND METHODS

We carried out a retrospective analysis of all consecutive patients treated for LAPC (N=33) between July 1997 and April 2005, analysing the results of first-line chemotherapy (CT group) and radio-chemotherapy (RCT group) in this setting.

RESULTS

The first-line treatment was RCT in six patients (18.3%) and CT in 26 patients (78.8%). Secondary treatment was administered to nine patients of CT group with well-controlled disease: "closure" radio-chemotherapy for seven patients (26.9%) and secondary resection for three (12%). After a median follow-up of 27 months, 23 patients died (69.7%). Overall survival was 13.8 months [95% CI: 10.1-19.4] for the whole population, 9.5 months [95% CI: 4.6-] for the RCT and 18.0 months [95% CI: 12.4-25.5] for the CT. Overall survival for the CT patients undergoing secondary surgery or "consolidation" radio-chemotherapy was 28.8 months [95% CI: 13.8-].

CONCLUSION

First-line chemotherapy is a valid option for LAPC treatment, making it possible to identify the patients who may benefit from secondary resection or radio-chemotherapy.

Long-term results of breast cancer irradiation treatment with low-dose-rate external irradiation

PURPOSE

The aim of this study was to assess beam therapy with low-dose-rate (LDR) external irradiation in a group of patients with breast cancer.

METHODS AND MATERIALS

This trial compared, from 1986 to 1989, patients with advanced breast cancer treated either by conventional fractionation or low-dose-rate (LDR) external radiotherapy (dose-rate 15 mGy/min, 5 sessions of 9 Gy delivered on 5 consecutive days).

RESULTS

A total of 21 patients were included in the fractionated therapy arm. At follow-up 15 years after treatment, 7 local recurrences had occurred, 3 patients had died of cancer, 18 patients were alive, 10 were without evidence of disease, and 6 had evidence of disease. A total of 22 patients had been included in the LDR arm of the study. Of these, 11 had received a dose of 45 Gy; thereafter, in view of severe local reactions, the dose was reduced to 35 Gy. There was no local recurrence in patients who had received 45 Gy, although there were 2 local recurrences among the 11 patients after 35 Gy. The sequelae were severe in patients who received 45 Gy but were comparable to those observed in patients treated by fractionated radiotherapy who received 35 Gy. The higher efficacy of tumor control in patients treated by LDR irradiation as well as the lower tolerance of normal tissue are probably related to the lack of repopulation.

CONCLUSION

Although the patient numbers in this study are limited, based on our study results we conclude that the data for LDR irradiation are encouraging and that further investigation is warranted.

Urinary continence after salvage radiation therapy following radical prostatectomy, assessed by a self-administered questionnaire: a prospective study

OBJECTIVE

To evaluate urinary continence after salvage radiotherapy following radical prostatectomy (RP) for clinically localized prostate cancer.

PATIENTS AND METHODS

In all, 145 men had a retropubic RP in our department between 1992 and 2000. From this group, salvage radiotherapy with the dose of 65 Gy was given to 18 patients for a rising prostatic specific antigen (PSA) level. The mean (range) age at RP was 63 (50-72) years and the initial PSA level 14.95 (4.8-34) ng/mL. The radiotherapy was given at 46 (6-96) months after RP. A self-administered questionnaire about their urinary status was mailed to the patients before and 18 months after radiotherapy. The mean follow-up after radiotherapy was 34 (20-70) months.

RESULTS

Before radiotherapy, 17 patients were continent (defining continence as no regular use of pads). After salvage radiotherapy, 16 men had had no change in their urinary status, even for the one patient using pads. One patient with stress urinary incontinence showed a slight worsening of his urinary status after radiotherapy. Another patient who was continent before radiotherapy developed urgency with no urinary leakage. Fourteen men stated that they were very satisfied or satisfied about their urinary status after radiotherapy and four were mildly satisfied. Nine would undergo radiotherapy again even with their present continence status and nine probably would.

CONCLUSION

Using an anonymous self-administered questionnaire, salvage radiotherapy for a rising PSA level seems to be safe and does not worsen the continence achieved after RP in most patients.

Combination of vinorelbine, epirubicin, and cyclophosphamide as neoadjuvant chemotherapy for locally advanced breast cancer: phase II study

Achievement of a pathologic complete response after primary chemotherapy in breast cancer can predict long-term outcome. We have investigated a combination of epirubicin, cyclophosphamide, and vinorelbine as neoadjuvant chemotherapy in locally advanced breast cancer (LABC). From January 1997 to May 1999, 30 chemonaive patients were treated (T2 or T3 histologically proven invasive breast carcinoma). Treatment was vinorelbine 25 mg/m2 day 1 and day 3, epirubicin 30 mg/m2/d, days 1 to 3, cyclophosphamide 350 mg/m2/d, days 1 to 3, every 14 days for 4 courses. Twenty-nine patients were evaluable. Median age: 48 years (range: 28-66 years); 26 had ductal invasive carcinoma and 4 lobular invasive carcinoma; median tumor size: 7 cm; median number of induction cycles: four. Clinical objective response was seen in 24 patients (relative risk: 86%), 14 complete responses, 10 partial responses, four stable disease (no significant changes). Twenty-nine patients had surgical treatment. Pathologic response rate was complete response in 32% (no residual tumor), in situ carcinoma: 11%, invasive or unchanged tumor remaining: 57%. Ninety-eight cycles were administered; major toxicities were hematologic: grade IV Hb in 5% and grade IV neutropenia in 60% of cycles. Ten patients required hospitalization for febrile neutropenia. Other toxicities were mild to moderate. The vinorelbine/epirubicin/cyclophosphamide regimen resulted in a high pathologic complete response rate in LABC with a good tolerance profile, and warrants further evaluation.

Long-term results of neoadjuvant radiation therapy for breast cancer

Our aim was to determine the long-term outcome and the possible role of neoadjuvant (preoperative) radiation therapy for breast cancers unsuitable for primary conservative surgery. From 1977 to 1992, 75 unifocal non-inflammatory and non-metastatic T2 and T3 breast cancers were treated in our department. All these patients underwent initial radiotherapy, followed by secondary limited surgery. A population of 74 patients, aged from 32 to 82 years (median 56 years), presenting 49 T2 and 26 T3 tumors, was studied. Seventy-two patients (96%) underwent secondary tumorectomy and three patients (4%) reduction mammaplasty. The secondary tumorectomy was followed by a postoperative boost. There were nine recurrences, treated by mastectomy in eight cases and by tumorectomy in one case. Twenty-five patients showed secondary dissemination. Forty-seven patients are still alive and free of disease. The cosmetic results were considered excellent or satisfactory in 71 cases. Under good conditions, preoperative radiotherapy (as well as preoperative chemotherapy) allows the possibility of conservative surgery for cancers of more than 3 cm. The choice between the two modalities depends on the patient's condition and on a precise analysis of all prognostic factors that would justify the need for systemic treatment.

Stewart-Treves syndrome after treatment for breast cancer

This study reviews 3 cases of angiosarcoma of the upper extremity after mastectomy and radiotherapy for breast cancer (Stewart-Treves syndrome). Angiosarcoma was diagnosed an average 14 years (from 6.5 to 26 years) after treatment for breast cancer. Presenting signs included a red raised lesion, a palpable mass, a blister appearance (in one case). Two of our three patients underwent surgical treatment: one patient underwent local excision followed by chemotherapy, and the other patient wide excision, followed by external beam radiotherapy. Local recurrence occurred in one of these two patients and was followed by the development of lung metastases. The second patient who had treatment is free of disease without problems. The third patient refused any treatment and died 5 months later. The purpose of this article is to add to the literature 3 new cases of Stewart-Treves syndrome and to discuss some specific problems of this rare tumour.

[Radiation-induced sarcoma after breast cancer. Apropos of 8 cases and review of the literature]

PURPOSE

Retrospective analysis of eight new cases of radiation-induced sarcomas following radiotherapy for breast carcinoma and literature review.

PATIENTS AND METHODS

Eleven patients presenting with radiation-induced sarcoma after radiotherapy for breast cancer have been treated between 1983 and 1997 at Henri Mondor University Hospital (France). Eight of these patients respected the criteria established by Cahan et al. The others had Stewart-Treves Syndrome and were thus excluded from the analysis. Only one of the eight patients had received chemotherapy. All of the patients at the time of diagnosis of radiation-induced sarcoma were free of breast cancer recurrence. Radiation-induced sarcoma appeared with a latency period of 5 to 18 years (mean: 10.3 years). Patients' ages ranged from 39 to 88 years (mean: 57.6 years) at the time of diagnosis of sarcoma. Three sarcomas occurred in the treated breast, two in the chest wall, one in the preclavicular area and two in the axillary region. There were two angiosarcomas, three fibrosarcomas, one osteosarcoma, one malignant fibrous histiocytoma (MFH), and one undifferentiated sarcoma. All patients have received treatment for their sarcoma: all of them underwent surgery, one patient combined radiotherapy and chemotherapy, and three patients chemotherapy.

RESULTS

Two patients were alive and free from disease. Six patients died (5-34 months); all six had local and/or metastatic recurrence.

CONCLUSIONS

Radiotherapy can induce malignancies after a latent period of several years. Radiation-induced sarcomas are associated with poor overall prognosis. The treatment in most of the cases is late and ineffective, therefore careful follow-up is needed. There are still many uncertainties and questions about radiation-induced sarcomas.

[Value of reduction mammoplasty in the conservative treatment of breast neoplasms. Apropos of 70 cases]

Breast cancer surgery is on the increase. Until now conservative treatment has been limited to tumors less than 3 cm; it is now extending to surgery on reduced tumors after chemotherapy or radiotherapy. Some cancers still require mastectomy because a carcinologic satisfactory tumorectomy would create a major deformity not compatible with conservative treatment. It is technically possible to perform major tumor resection with good cosmetic results using the reduction mammoplasty technique well known in plastic surgery. Between 1983 and 1991, 70 patients were treated at Henri Mondor Hospital for breast cancer with breast reduction mammoplasty and irradiation. We present the result with an average five years follow-up in terms of the cosmetic results relapses and survival rate. The actuarial local relapse was less than 10%, the survival with local relapse was 86% after 5 years, cosmetic results were good in 81% of cases. The association of reduction mammoplasty and radiotherapy seems to be a good extension of conservative treatment in some large breast tumors.

Management of breast cancer in the elderly

The management of breast cancer in elderly women was analysed by a retrospective study of 150 women over 70 years old referred to our department between 1984 and 1988. 80 were T1-T2, 33 were T3 and 34 were T4. 107 were N0 and 43 were N1-N2. 16 women (11%) were in poor health, preventing conventional treatment. Treatment choice varied with age: 60% of the women aged 70-79 (group 1) and 23% of the oldest women (group 2) were treated conventionally. The use of surgery decreased with age and surgical procedures were conventional in only 85% of the group 1 women and in 56% of the group 2 women. Definitive radiation therapy was used more frequently in the oldest women, as was primary hormone therapy. Quality of follow-up also varied with age. Five-year survival rates were still high in both groups while relapses were frequent. Breast cancer was consequently a frequent cause of death. The increase in the proportion of elderly people with breast cancers over the next few years will require validated guidelines. Specific protocols and specific rules of management must be drawn up.

Time factors in breast carcinoma: influence of delay between external irradiation and brachytherapy

From 1971 to 1983, 398 (33 T1, 309 T2, 56 T3) biopsy-proven breast adenocarcinomas were treated conservatively at Hôpital Henri Mondor by an initial course of external irradiation (45 Gy, 25 fractions, 5 weeks) followed by interstitial iridium-192 implant for a further 37 Gy to the tumor. The mean interval between external irradiation and brachytherapy was 5.9 weeks (S.D. 1.7, range 1-18). Seventy-seven local failures were observed at 10-148 months (median 34.5). The actuarial probabilities (S.E.) of local control at 5 and 10 years were 0.86 (0.02) and 0.74 (0.03), respectively. The follow-up for patients free of local recurrence was 4-205 months (median 95). Multivariate analysis showed an increasing probability of local failure with longer interval between external irradiation and brachytherapy (Relative Risk [R.R.] 1.23 [95% confidence limits: 1.07, 1.41] per week, p = 0.005), and a lower risk of failure in case of complete tumor regression after external irradiation (R.R. 0.47 [0.25, 0.90], p = 0.022), and higher brachytherapy dose rate (R.R. 0.13 [0.02, 1.02] per Gy/h, p = 0.053). No influence of tumor size and total dose (possibly because only limited variations in total dose were observed), or histological grading (not performed in 140 [35%] patients) was found. Because of the lack of dose-control relationship, quantification of the effects of delay between external irradiation and brachytherapy (in terms of compensatory dose) and of dose rate (Incomplete Repair Model) was not possible.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of dose rate on local control of breast carcinoma treated by external beam irradiation plus iridium 192 implant

From 1971 to 1983, 20 T1, 267 T2, and 53 T3 biopsy-proven adenocarcinomas of breast were definitively managed by radiotherapy. The breast and regional nodes received 45 Gy of 60Co irradiation in 25 fractions over 5 weeks (45 Gy/25/5 wks). Electrons were used to deliver a further 15 Gy/7/1.5 weeks to the internal mammary chain and 25 Gy/11/2.5 weeks to the lower axilla. The primary tumor was boosted by Iridium 192 implant for a further 37 Gy prescribed at 85% of the basal dose rate (Paris system). Rigid needles were secured by templates in single plane (58/398) or double plane (340/398) geometry. Results of the 340 two-plane implants have been analyzed to look for a possible influence of dose rate on local control. Follow-up for patients free of local recurrence is 4-204 months (median: 92 months). The 340 tumors were divided into three groups according to dose rate: 0.32-0.49 Gy/hr (n = 95), 0.50-0.59 Gy/hr (n = 120), and 0.60-0.90 Gy/hr (n = 125). The three groups are statistically comparable according to age, tumor size, mean 60Co dose, mean Iridium dose, overall treatment time, and follow-up. The local failure rate in the three groups is 27% (26/95), 20% (24/120), and 13% (16/125) (p less than 0.03, Chi square). At 15 years the estimated local control (Kaplan Meier) is 60%, 72%, and 84% (p less than 0.02, Logrank), respectively. This analysis indicates that there is a significant effect of dose rate on local control for carcinoma of the breast treated by combined external beam (45 Gy) plus Iridium 192 implantation (37 Gy). To maximize local control the authors recommend an implant dose rate of greater than or equal to 0.6 Gy/hr.

External irradiation prior to conservative surgery for breast cancer treatment

From 1981 to 1987, 138 patients with breast cancer unsuitable for primary tumorectomy received initial external radiotherapy (45 Gy/25f/35d) in order to reduce the tumor volume so that secondary limited surgery could be performed. There were 81 T2 and 57 T3. Fifty-seven percent of the patients had a tumor larger than 4.5 cm. After completion of the radiotherapy, 22 patients (16%) showed no more evidence of a tumor either clinically or radiologically and received a boost of 25 Gy. In 52 cases (38%) the tumor regression allowed for secondary tumorectomy followed by a boost of 20 Gy. Sixty-four patients (46%) showed either little or no tumor regression: radical surgery was performed in 14 cases (10%) and high dose boost curietherapy (37 Gy) in the 50 (36%) remaining patients who refused mastectomy. Breast conservation in good condition was thus obtained in 74 patients (54%). Sufficient tumor regression to allow secondary tumorectomy was more often observed in T2 than in T3, in poorly differentiated tumors or mucinous type, and in tumor with well defined mammographic aspects. Actuarial 5-year local control and disease-free survival rates after limited surgery were, respectively, 90% and 73%. No particular complications were observed after secondary tumorectomy. This therapeutic approach is encouraging in patients with large T2 and T3 breast tumors, but a longer follow-up is required to assess definitive conclusions.

Conservative treatment for breast cancer: long-term results (15 years)

From 1961 to 1974, 245 patients with unilateral "operable" breast cancer (25% T1, 56% T2, 19% T3) were treated with breast conservation and irradiation at the Gustave Roussy Institute (1961-1969) or at the Henri Mondor Hospital (1970-1974). The minimum follow-up is 15 years. Most patients with T greater than 3 cm underwent radiation therapy with the tumor in place, while the greater part of patients with T less than 3 cm received radiation therapy after tumorectomy. The breast and draining lymph node areas received widefield telecobalt irradiation to 45 Gy. The dose to the tumor site was boosted using iridium-192 implantation. Additional irradiation was given to the internal mammary and lower axillary nodes using an electron beam. The 15 years NED survival rate was 63%, 51% and 26% for T1, T2 and T3 tumors, respectively. The NED survival for T less than or equal to 1 cm was 86%. The local recurrence rate was 8, 12 and 19% for T1, T2 and T3 tumors, respectively. Of the patients with local recurrence, 85% underwent surgical salvage. Complications were rare. Cosmetic results were satisfactory in most patients including the T3 group. The proportion of breasts conserved among patients living NED at 15 years, was 97, 88 and 93% for T1, T2 and T3 tumors, respectively. In 1980, after almost 20 years experience using breast conserving techniques, we modified our treatment policies in close collaboration with our surgical team, hel cbye extending the indications for tumorectomy and associating routine surgical exploration of the lower axilla.

[Can tumors of the breast larger than 3 centimeters be treated conservatively?]

Unlike small breast cancers, which are now treated conservatively by primary tumorectomy, the most important lesions (T2 and T3) as usually treated tumorectomy, the most important lesions (T2 and T3) as usually treated by mastectomy. However, in patients with these large lesions attempts may be made at conserving the breast with reliable oncological safety and good cosmetic results. Depending on clinical presentation, one or the other of two therapeutic approaches may be considered. The most common treatment is preoperative radiotherapy of 45 Gy which, in more than 50 p. 100 of the cases results in a tumoral regression that is sufficient for secondary tumorectomy to be performed. In some patients, the first-line treatment consists of wide tumoral excision as part of a reductive mammaplasty, followed by radiation.

Conservative management of tumors of the rectum by radiotherapy and local excision

Twenty-five patients with invasive adenocarcinoma of the rectum were treated by preoperative external irradiation (35 Gy), local excision, and peroperative placement of a plastic tube loop in the tumor bed for perioperative brachytherapy (20 or 25 Gy). Patients treated were too frail for radical resection (14 patients) or had refused a permanent colostomy (11 patients). With a mean follow-up of 40.5 months, there have been 5 patients with local relapse, 3 of whom had salvage abdominoperineal resections: 2 have no evidence of disease and 1 has developed distant metastatic disease. The 20 patients with local control have normally functioning sphincters; 1 has developed distant metastatic disease. This combined approach was designed to expand the curative role of local resection in carcinoma of the rectum. The surgical techniques are thoroughly described and the potential role and indications of this approach are discussed.

[A new conservative approach in the treatment of cancer of the rectum]

Between 1980 and 1987, 25 patients with cancer of the middle or lower rectum were treated with preoperative radiotherapy (35 Gy over 3 weeks) followed, a few weeks later, by "tumorectomy". During surgery, a guiding tube was positioned on the tumoral bed for a localized overdose of curietherapy. The superimpression was 20 Gy for submucosal lesions (7 patients) and 25 Gy for lesions that had invaded the muscle coat (8 cases) or reached the serous coat (10 cases). During a mean follow-up period of 40.5 months, there were 5 recurrences and they all appeared before 18 months had elapsed since the end of treatment. Two of these 5 patients are alive and without metastasis 1 year after a secondary abdominoperineal rectal amputation. The 20 patients who showed no recurrence have normal sphincter function and 19 of them are now alive without evidence of malignancy. In cancer of the middle or lower rectum this conservative approach seems to be suitable for patients who cannot benefit from radical surgery or refuse abdominoperineal rectal amputation.

A new combined approach in the conservative management of rectal cancer

Between 1980 and 1987, 25 patients with rectal cancer were treated with a combination of preoperative external irradiation of 35 Gy in 15 fractions over 3 weeks which was followed, 6 to 8 weeks later, by a tumorectomy and peroperative placement of a plastic tube loop for post-operative interstitial therapy by iridium-192. This boost dose was 20 Gy (Paris System) for submucosal lesions (seven patients) and 25 Gy for intramural (eight patients) and extramural (ten patients) lesions. With a mean follow-up of 40.5 months, there have been five local recurrences, the latest occurring 16 months post-tumorectomy. Two of these five patients are alive and disease-free 1 year post salvage abdominoperineal resection. The 20 patients with local control have preserved a full functional sphincter and 19 of them are disease-free; there were few complications. This sphincter preserving combined approach seems promising for patients with tumors of the middle and lower rectum who cannot undergo major surgery and for selected patients who refuse abdominoperineal resection.

High-dose chemotherapy, total abdomen irradiation and autologous bone marrow infusion in ovarian cancer: an observation

A case of treatment of an ovarian adenocarcinoma (stage IIIc of the IFGO) is reported. The patient underwent a maximal tumor reduction followed by polychemotherapy. After this treatment, a 'second-look' laparotomy shows an incomplete remission. An intensive chemotherapy with total abdomen irradiation and protection of medullary toxicity by an autologous bone marrow infusion is performed, with a satisfactory result, without relapse, 16 months after this treatment (or 25 months after the first laparotomy). Reasons which led the authors to perform an autograft and the conditions under which this treatment may be offered are then presented.

[Can the indications of conservative radiosurgical combination in the treatment of breast cancer be extended?]

In the hope that women with breast cancer unsuitable for primary tumorectomy would benefit from a conservative treatment, we tried to reduce the lesional volume by an initial irradiation of 45 Gy administered in 25 fractions over 35 days. This treatment was applied to 111 patients (69 T2; 42 T3). In 44 cases (40 per cent), tumoral regression enabled a secondary tumorectomy to be performed. In 16 cases (14 per cent), the tumour totally disappeared, and an additional irradiation by endocurietherapy in intermediate dosage could be given. In 51 patients (46 per cent), the tumoral response was poor and the patients underwent, depending on their wishes, either mammectomy (9 cases; 8 per cent) or high-dose endocurietherapy (42 cases; 38 per cent). Analysis of tumoral regression according to size, histological type and mammographic image provided for a better identification of good responders. The cosmetic and oncological results of this preliminary study are satisfactory, with a 95 per cent local control at 5 years after secondary tumorectomy.

Treatment of inflammatory breast cancer with combination chemotherapy and mastectomy versus breast conservation

Twenty-six consecutive patients with nonmetastatic inflammatory breast cancer (IBC), were treated in a single institution using the same protocol, and all were followed for at least 48 months. The first phase of treatment consisted of two monthly cycles of combination chemotherapy with Adriamycin (Adria Laboratories, Columbus, OH), vincristine, cyclophosphamide and 5-fluorouracil. Local treatment was then undertaken using in all cases a cobalt 60 beam to deliver 45 Gy to the entire mammary gland and lymph-draining areas. Local treatment was completed either by mastectomy, or by conservation of the breast and interstitial irradiation of the primary tumor site. Chemotherapy was resumed after completion of local treatment for a total of 6 cycles. Metastatic disease occurred in 19 of 26 patients from 8 to 55 months; five patients are alive and free of disease from 48 to 81 months. Failure to control local disease or local recurrences was noted in two of ten patients undergoing mastectomy, and in seven of 13 patients with conservation of the breast. While this difference is not statistically significant we concluded that methods of breast conservation which limit the high dose volume to the tumor site do not assure local control in IBC. The median disease-free survival and overall survival of 12 and 31 months, respectively, are not satisfactory. Better systemic treatment is needed.

[Treatment of advanced cancer of the ovary using intensive chemotherapy with autograft of bone marrow. From a case, discussion and review of the literature]

A case of treatment of an advanced ovarian adenocarcinoma (Stage IIIc of the FIGO) is reported. The patient underwent a maximal tumor reduction followed with polychemotherapy. After this treatment, a "second look" laparotomy shows an incomplete remission. An intensive chemotherapy with abdomini-pelvic radiotherapy and protection of medullary toxicity by a bone marrow autograft is performed, with a satisfactory result, without relapse, 16 months after this treatment (or 25 months after the first laparotomy). A review of the literature concerning the treatment to be undertaken following the "second look" operation, is briefly exposed. Reasons which led the authors to perform an autograft and mostly the conditions under which this treatment may be offered, are then presented.

[Conservative treatment of breast cancer. Results after 10 years]

Between 1961 and 1975, 300 women with cancer of the breast (T1:72; T2:167; T3:61) were treated conservatively with radiotherapy alone (T3) or with partial or predominant radiotherapy combined with tumorectomy without axillary dissection (T1 or T2). The results, normalized at 10 years, confirmed that the survival rate (crude or NED) was exactly the same as with other conservative treatments or mutilating surgical treatments. Relapses were few (8%) in T1 cases and acceptable in T2 and T3 cases (13% and 18% respectively); in almost every patient they were amenable to surgery, with good local postoperative course. The prevalence of metastases was directly proportional to the size of the tumour; it was neither more nor less frequent than after radical surgery. Complications were rare and not very severe. Cosmetic results were either excellent (T1) or satisfactory (T2, T3). Finally, the proportions of breasts preserved at 10 years among patients alive and NED was very high, ranging from 96% (T1) to 91% (T2) and 87% (T3). These good results were associated with the possibility of high dosage additional endocurietherapy of the tumoral area with iridium 192, particularly in extensive forms where tumorectomy was cosmetically precluded. Since 1975, we have been using the conservative treatment in closer association with non mutilating surgery.

Locoregional recurrences following radical external beam irradiation and interstitial implantation for operable breast cancer--a twenty three year experience

Locoregional recurrences are reported in 493 consecutive with T1 T2 N0 N1 breast cancer patients who were treated with radical external beam irradiation and interstitial 192 Ir. implant between 1961 and 1979. Follow-up ranges from 5-23 years (mean 10 years) with 195 patients having 10-23 years follow up (mean 12 years). Tumorectomy was performed in 130/158 (88%) T1 and 73/335 (22%) T2 patients. There were 51 (10%) locoregional recurrences with 34 mammary, 14 combined mammary/axillary and 3 isolated axillary recurrences. The 10 year relapse rate was 20/195 (10%). The risk, timing and site of relapse varied according to TNM stage and tumorectomy. The risk was higher for T2 (42/335, 12.5%) than T1 (9/158, 5.5%) due to a larger number of recurrences occurring in the first 5 years (T2 32/335, 9.5% vs T1 4/158, 2.5%). Between 5-10 years, risk of relapse equalized to around 3% for both groups and only 1 relapse was seen after 10 years. Of the 48 mammary recurrences, 25 (52%) occurred in the implant volume, 7 (14%) occurred on the margin of the implant, 12 (25%) occurred at sites remote from the primary and in 4 (9%), the exact site could not be defined. 14/48 mammary recurrences were accompanied by axillary relapse, there were 3 isolated axillary recurrences and supraclavicular metastases accompanied axillary relapse in 3 cases. The overall risk, of axillary relapse was 3% (17/493) and there was significant correlation with initial N stage. Salvage surgery generally mastectomy and axillary dissection, was possible in 45/51 (90%) recurrences. 23/45 (50%) survive NED 0.2-9 years (mean 3 years) after salvage. 8/23 (35%) followed longer than 5 years after salvage survive NED. Our results have been compared with other series in the literature and changes in our current protocol are described.

Conservative management of breast carcinoma. The Créteil experience

The results of conservative management of breast carcinoma are presented. The disease free survival for patients with T1 lesions was 84 per cent at 5 years, 76 per cent at 7 years and 65 per cent at 10 years, for T2 75, 71 and 64 per cent, and for T3 65, 51 and 45 per cent. The proportion of breast conserved amongst the patients free of disease at 10 years was 94 per cent for T1, 93 per cent for T2 and 80 per cent for patients with T3 lesions. The cosmetic results were very good for T1 lesions, good for T2 and quite good for T3 lesions. Up to 1981 a simple tumorectomy was carried out in most of the T1 lesions and some of the T2 lesions, followed by radical irradiation. Most of the T2 and T3 lesions were exclusively treated with radical irradiation. In an attempt to improve the cosmetic results, since 1981, the indications for tumorectomy were extended to include some of the T2 lesions, and when possible also some of the T3 lesions, where a tumorectomy is performed before or after irradiation, together with a limited axillary dissection.