The star approach, a surgical approach for skin sparing mastectomy and central lumpectomies

When preservation of the nipple-areolar complex (NAC) is not possible in oncologic breast surgery, the traditional approaches are either a horizontal incision centered on the NAC resulting in visible scars and breast distortion, or a round block with risk of healing difficulties. To address these concerns, the authors propose a star approach technique for skin sparing mastectomies and lumpectomies of central breast tumors. During the oncologic surgery, the NAC is removed with four cutaneous extensions, which can be closed as a cross-shaped scar. The scarring is similar in size to the original NAC diameter and can easily be covered by the NAC reconstruction. This technique offers good exposure during surgery, a good aesthetic result with limited scarring, no breast deformity, correction of breast sagging, and high-quality healing.

Optimal biological dose: a systematic review in cancer phase I clinical trials

BACKGROUND

Classical phase 1 dose-finding designs based on a single toxicity endpoint to assess the maximum tolerated dose were initially developed in the context of cytotoxic drugs. With the emergence of molecular targeted agents and immunotherapies, the concept of optimal biological dose (OBD) was subsequently introduced to account for efficacy in addition to toxicity. The objective was therefore to provide an overview of published phase 1 cancer clinical trials relying on the concept of OBD.

METHODS

We performed a systematic review through a computerized search of the MEDLINE database to identify early phase cancer clinical trials that relied on OBD. Relevant publications were selected based on a two-step process by two independent readers. Relevant information (phase, type of therapeutic agents, objectives, endpoints and dose-finding design) were collected.

RESULTS

We retrieved 37 articles. OBD was clearly mentioned as a trial objective (primary or secondary) for 22 articles and was traditionally defined as the smallest dose maximizing an efficacy criterion such as biological target: biological response, immune cells count for immunotherapies, or biological cell count for targeted therapies. Most trials considered a binary toxicity endpoint defined in terms of the proportion of patients who experienced a dose-limiting toxicity. Only two articles relied on an adaptive dose escalation design.

CONCLUSIONS

In practice, OBD should be a primary objective for the assessment of the recommended phase 2 dose (RP2D) for a targeted therapy or immunotherapy phase I cancer trial. Dose escalation designs have to be adapted accordingly to account for both efficacy and toxicity.

GUIP1: a R package for dose escalation strategies in phase I cancer clinical trials

BACKGROUND

The main objective of phase I cancer clinical trials is to identify the maximum tolerated dose, usually defined as the highest dose associated with an acceptable level of severe toxicity during the first cycle of treatment. Several dose-escalation designs based on mathematical modeling of the dose-toxicity relationship have been developed. The main ones are: the continual reassessment method (CRM), the escalation with overdose control (EWOC) method and, for late-onset and cumulative toxicities, the time-to-event continual reassessment method (TITE-CRM) and the time-to-event escalation with overdose control (TITE-EWOC) methods. The objective of this work was to perform a user-friendly R package that combines the latter model-guided adaptive designs.

RESULTS

GUIP1 is an R Graphical User Interface for dose escalation strategies in Phase 1 cancer clinical trials. It implements the CRM (based on Bayesian or maximum likelihood estimation), EWOC and TITE-CRM methods using the dfcrm and bcrm R packages, while the TITE-EWOC method has been specifically developed. The program is built using the TCL/TK programming language, which can be compiled via R software libraries (tcltk, tkrplot, tcltk2). GUIP1 offers the possibility of simulating and/or conducting and managing phase I clinical trials in real-time using file management options with automatic backup of study and/or simulation results.

CONCLUSIONS

GUIP1 is implemented using the software R, which is widely used by statisticians in oncology. This package simplifies the use of the main model-based dose escalation methods and is designed to be fairly simple for beginners in R. Furthermore, it offers multiple possibilities such as a full traceability of the study. By including multiple innovative adaptive methods in a free and user-friendly program, we hope that GUIP1 will promote and facilitate their use in designing future phase I cancer clinical trials.

P04.02 Postponing the medical treatment is possible in selected cases of diffuse low-grade glioma with foci of WHO grade III-IV after total or subtotal resection

BACKGROUND

Diffuse low-grade gliomas (DLGG) are defined by a continuous growth and an unavoidable malignant transformation. Foci of malignant transformation may be found within DLGG samples obtained from surgical resections. As the medical management is classically based on the higher tumor grade, an immediate adjuvant treatment is usually proposed (radiotherapy [RT] with Temozolomide or PCV), whatever the extent of resection. Yet, early RT has no impact on overall survival compared with late RT, and is associated with cognitive toxicity. An alternative approach consists in postponing the medical treatment in selected patients.

MATERIAL AND METHODS

We conducted a monocentric retrospective analysis of a consecutive series of patients managed with this conservative approach. Inclusion criteria were: DLGG (WHO 2016 grade II) with at least one focus of malignant transformation (grade III-IV); no previous chemotherapy or RT; no less than a subtotal resection of the FLAIR tumor volume; no intention of treating with immediate adjuvant therapy; at least two years of postoperative follow-up. The time interval to the next medical treatment (chemotherapy and/or radiotherapy) was assessed, as well as the functional and survival results.

RESULTS

Forty-five DLGG patients, of median age 36.5 years, were included in the analysis (median time interval from diagnosis: 7.3 months). The histo-molecular diagnosis was diffuse astrocytoma, IDH mutant in 46.7% of cases, astrocytoma, IDH wild-type in 13.3% and oligodendroglioma, IDH mutant and 1p/19q codeleted in 40.0%. Ten tumors presented with grade IV foci. The quality of resection was subtotal (FLAIR tumor residue ≤15 cm3) in 73.3%, total (no FLAIR tumor residue) in 24.4% and supratotal in 2.2%. After surgery, patients were managed with regular clinical and radiological follow-up. With a median postoperative follow-up of 6.3 years, 75.5% of patients received a subsequent medical treatment, after a median time interval of 3.7 years. The first treatment after surgery consisted of repeated surgery in 11 patients, Temozolomide in 28 patients, RT in one patient. At the time of analysis, 19 patients (42.2%) had been treated with RT, after a median time interval of 9.5 years. Nine patients (20.0%) had died (median overall survival not reached, 5-years and 7-years survival rates: 95.2% and 67.0%). Most surviving patients were still active professionally (69.4%), with a median Karnofsky performance status of 90, and no or rare seizures.

CONCLUSION

In this series, total or subtotal resection of DLGG with a least one focus of grade III-IV glioma radically changed the natural history of these tumors and allowed delaying the following medical treatment by several years. This strategy is feasible in selected patients and should be considered on a case-by-case basis in patients with foci of malignant transformation following total or subtotal resection.

Abstract P6-14-02: Real-life activity of eribulin among metastatic breast cancer patients in the multicenter national observational ESME program

Background: In 2014, UNICANCER (composed of 18 French Comprehensive Cancer Centers) launched the Epidemiological Strategy and Medical Economics (ESME) program to investigate real-world data in solid tumors. Real-world data give the opportunity to assess for the activity of specific drugs outside clinical trials. Eribulin is approved for pre-treated metastatic breast cancer (MBC). Marketing authorization has been granted in France in July 2012. However few data are available regarding its efficacy in real life. We evaluated eribulin use as second and third line of chemotherapy in MBC patients from the ESME database.

Methods: Data from all newly diagnosed MBC patients having initiated at least one treatment between Jan. 2008 and Dec. 2014 are included in the ESME database. Data were collected retrospectively using a clinical trial-like methodology. Primary endpoint was overall survival (OS), defined from the starting date of second or third line chemotherapy (eribulin versus other chemotherapy). Progression-free survival (PFS) was calculated as a secondary endpoint.

Results: Of 16,703 MBC patients included in the ESME database, 7,412 received at least 2 lines of chemotherapy: eribulin/other chemotherapy, total 1,966/5,446, second line 363/5,446, third line 654/2,669. Depending on second or third line chemotherapy use classification, median age was 59 years (range 20-97) and 58 year (range 21 – 94), triple negative tumors accounted for 20% and 19% of cases, and median follow-up reached 26 months and 22 months respectively.

Table reports median OS and PFS, according to lines and type of chemotherapy.

 OS eribulin (months)OS other chemotherapy (months)pPFS Eribulin (months)PFS other chemotherapy (months)pSecond line12.4 (11.3-15.1)11.8 (11.3-12.3)0.4654.1 (3.7-4.9)4.1 (4.0-4.3)0.9225Third line10.3 (9.3-11.5)7.7 (7.3-8.0)<.00013.6 (3.2-3.9)3.0 (2.9-3.2)0.0058

Supportive analyses (using a propensity score for adjustment and as a matching factor for nested case–control analyses) and sensitivity analyses will be available for full presentation at the meeting.

Conclusion: In this large-scale real-life setting, MBC patients treated with third line eribulin showed an improved OS and PFS compared with those receiving another chemotherapy. The difference was not statistically significant for second line treatment.

Citation Format: Jacot W, Heudel P-E, Fraisse J, Gourgou S, Guiu S, Dalenc F, Pistilli B, Campone M, Levy C, Debled M, Leheurteur M, Chaix M, Lefeuvre C, Goncalves A, Uwer L, Ferrero J-M, Eymard J-C, Petit T, Mouret-Reynier M-A, Courtinard C, Cottu P, Robain M, Mailliez A. Real-life activity of eribulin among metastatic breast cancer patients in the multicenter national observational ESME program [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-14-02.

A multicenter cohort study to compare quality of life in breast cancer patients according to sentinel lymph node biopsy or axillary lymph node dissection

BACKGROUND

This prospective multicenter study assessed and compared the impact of different surgical procedures on quality of life (QoL) in breast cancer patients.

PATIENTS AND METHODS

The EORTC QLQ-C30 and the EORTC QLQ-BR-23 questionnaires were used to assess global health status (GHS), arm (BRAS) and breast (BRBS) symptom scales, before surgery, just after surgery and 6 and 12 months later. The Kruskal-Wallis test with the Bonferroni correction was used to compare scores. A mixed model analysis of variance for repeated measurements was then applied to assess the longitudinal effect of surgical modalities on QoL.

RESULTS

Before surgery, GHS (P = 0.7807) and BRAS (P = 0.7688) QoL scores were similar whatever the surgical procedure: sentinel node biopsy (SLNB), axillary node dissection (ALND) or SLNB + ALND. As compared with other surgical groups, GHS 75.91 [standard deviation (SD) = 17.44, P = 0.041] and BRAS 11.39 (SD = 15.36, P < 0.0001) were better in the SLNB group 12 months after surgery. Whatever the type of surgery, GHS decreased after surgery (P < 0.0001), but increased 6 months later (P = 0.0016). BRAS symptoms increased just after surgery (P = 0.0329) and until 6 months (P < 0.0001) before decreasing (P < 0.0001).

CONCLUSIONS

SLNB improved GHS and BRAS QoL in breast cancer patients. However, surgeons must be cautious, SLNB with ALND results in a poorer QoL.

A nomogram predictive of non-sentinel lymph node involvement in breast cancer patients with a sentinel lymph node micrometastasis

PURPOSE

Predictive factors of non-sentinel lymph node (NSN) involvement at axillary lymph node dissection (ALND) have been studied in the case of sentinel node (SN) involvement, with validation of a nomogram. This nomogram is not accurate for SN micrometastasis. The purpose of our study was to determine a nomogram for predicting the likelihood of NSN involvement in breast cancer patients with a SN micrometastasis.

METHODS

We collated 909 observations of SN micrometastases with additional ALND. Characteristics of the patients, tumours and SN were analysed.

RESULTS

Involvement of SN was diagnosed 490 times (53.9%) with standard staining (HES) and 419 times solely on immunohistochemical analysis (IHC) (46.1%). NSN invasion was observed in 114 patients (12.5%), whereas 62.3% (71) had only one NSN involved and 37.7% (43) two or more NSN involved. In multivariate analysis, significant predictive factors were: tumour size (pT stage < or = 10 mm or >11 and < or = 20 or >20 mm [odds ratio (OR) 2.1 and 3.43], micrometastases detected by HES or IHC [OR 1.64], presence or absence of lymphovascular invasion (LVI) [OR 1.76], tumour histological type mixed or not [OR 2.64]. The rate and probability of NSN involvement with the model are given for 24 groups, with a representation by a nomogram.

CONCLUSION

One group, corresponding to 10.1% of the patients, was associated with a risk of NSN involvement of less than 5%, and five groups, corresponding to 29.8% of the patients, were associated with a risk < or = 10%. Omission of ALND could be proposed with minimal risk for a low probability of NSN involvement.

Localisation intrathoracique des tumeurs desmoïdes : à propos d'un cas familial de tumeurs desmoïdes isolées et revue de la littérature

We present the case of large desmoid tumor of the anterior chest wall with pleural involvement, which persistently progressed despite hormonotherapy, chemotherapy and surgery. After many years of therapeutic failures, given the tumor size and its hemodynamic repercussions, the patient was presumed to be incurable and only supportive measures were given. One year later, the desmoid tumor had completely disappeared. Even though wide surgical excision is an essential element in the treatment of desmoid tumors, spontaneous regression may occur in very advanced disease.

Malignant extraovarian endometriosis: A review

AIMS

Malignant transformation in extra-ovarian endometriosis is a rare but known complication. This distinct pathological entity is reviewed with a specific focus on aetiology and treatment.

METHODS

Studies were identified by searching the English language literature in the MEDLINE database and by an extensive review of bibliographies from articles found through that search.

FINDINGS

Up to 1% of women with endometriosis will develop endometriosis-associated neoplasm. Almost a quarter of the reported cases of malignancy in endometriosis have involved extra-ovarian tissues. In many cases, hormonal factors may play a role in its pathogenesis. Estrogen monotherapy in obese patients significantly increase the risk of malignant extra-gonadal endometrial transformation. Genetic anomalies have also been reported such as loss of heterozygosity on chromosome 5q. For patients with disease confined to the site of origin, a 82-100% 5-year survival has been noted for endometrioid cell type; disseminated intraperitoneal disease, however, has a very poor associated prognosis, with a 0-12% 5-year survival overall.

CONCLUSIONS

Women with endometriosis-associated cancers most likely represent a different class of patients than traditional ovarian cancer patients and may require different therapeutic options.

Prise en charge des lésions urétérales iatrogènes

Ureteral injury is a rare but potential serious complication that can occur during a variety of general surgical procedures. Knowledge of the course of the ureter is the first step toward preventing ureteral injuries. While some injuries are noticed intraoperatively, most are missed and present later with pain, sepsis, urinary drainage or renal loss. The choice of treatment is based on the location, type and extend of ureteral injury. For injuries recognized during open surgery, when involving the distal 5 cm of the ureter, an antireflux ureterocystostomy such as the Politano-Leadbetter procedure or a vesicopsoas hitch can be performed. For the middle ureter, an ureteroureterostomy is satisfactory and for the proximal ureter, most injuries can be managed by transureteroureterostomy. In complex situations intestinal interposition, autotransplantation or even nephrectomy can be considered. The majority of patients with delayed diagnosed ureteral injuries should be managed by an initial endo-urologic approach.

The role of surgery and treatment trends in uterine sarcoma

AIMS

To report a series of uterine sarcomas treated in one institution.

METHODS

We report 72 cases of uterine sarcomas treated in a single institution, comparing the periods 1966-1989 and 1990-2001. The parameters studied were histological type, tumour stage and treatment. The control of pelvic, local and/or metastatic disease were also studied.

RESULTS

The histological types consisted in 34 leiomyosarcomas, 25 mixte mullerian tumours, 12 endometrial stromal sarcoma and one angiosarcoma. The median age at diagnosis was 60.5 years. The presenting symptoms were genital bleeding, pelvic or abdominal pain. The proportion, of stage I was lower in 1966-1989 than in 1990-2002. During the 1966-1989 period, surgery was systematically used. The percentage of second-line surgery (post-radiotherapy or -chemotherapy) rose from 2.2% in 1966-1989 to 19.2% in 1990-2002. Radiotherapy was administered in 55.5% of cases. There was no difference between the two periods. Chemotherapy was administered in 37.5% of cases with also no difference between the two periods. The overall 2-year survival was 54.6% and the 5-year survival 36.1%. The median survival was 32.3 months (3 days-25 years). The overall 5-year survival by stage was 47.5% for stage I, 60.6% for stage II and 15.0% for stages III and IV. The median duration of pelvic disease control was 19.2 months. The 5-year pelvic disease control by FIGO stage was 66.6% for stage I, 62.5% for stage II and 18% for the more advanced stages.

CONCLUSION

Surgery remains the reference treatment. Local and regional disease control, as adjuvant therapies do not seem to decrease the risk of metastatic spread or increase survival.

[Evolution of therapeutic practices and survival of ovarian cancer in Bourgandi between 1982-1996: a registry-based study]

OBJECTIVE

The aim of this study is to describe the evolution of therapeutic practices and the evolution of survival between 1982 and 1996 in a population of ovarian carcinomas. All the patients were registered in the "Registre des Cancers Gynécologiques de Côte-d'Or-France".

POPULATION AND METHODS

During this period, 546 cases of ovarian cancers were registered. Data about FIGO staging at the diagnosis, histologic type, initial surgical procedures and survival were studied.

RESULTS

During this period, 61.7% of the patients had a complete resection of their tumor. The frequency of complete removal increased significantly during the period of this study. Complete removal moved from 56%, between 1982 and 1984, up to 75%, between 1993 and 1996. Complete removal was possible in 98.1% of the FIGO stage 1 cases while it was possible in only 18.3% of the stage IV. 76.9% of the patients younger than 50 years old had a complete removal while only 29% of the women older than 80 years old had a complete removal. Fifty percent of stage I received chemotherapy as long as 85% of patients younger than 50 years old. After 1993, only 2.6% of them had radiotherapy. The global survival rate at 5 years was 35.4%.

CONCLUSIONS

Surgery is the major procedure to obtain a complete remission of ovarian cancer. The efficacy of current chemotherapies may modify the initial management of these tumors, particularly in modifying the chronology of the different therapeutic sequences.

[Malignant tumours arising in extraovarian endometriosis: three case reports and review of the literature]

In its extraovarian form, co-existence of carcinoma and endometriosis is a sufficient argument used in favour of the malignant transformation of endometric lesions. Estrogen as well as the loss of 5q chromosome heterozygosity are considerate as initiators of that type of carcinogenesis. Endometrioid histological type is the most frequent and is revealed usually by abdominal pain. The incidence of carcinoma arising in endometriosis is about 0.8% and 5-year survival rate of pelvic endometrioid form is about a 100% after surgery and radiotherapy.

Concurrent lymphoma and metastatic breast carcinoma in the axillary, confounding sentinel lymph-node biopsy

We describe the case of a female patient who presented with the concurrence of two tumors, breast cancer and low grade lymphoma, in different nodes but in the same axillary lymphatic site. The sentinel node biopsy procedure for the detection of carcinoma cells in two well-identified sentinel nodes which had been colonised by lymphoplasmocytic cells was negative. Tumor collision lead to a mistake in the appropriate staging of the breast tumor by sentinel lymph-node biopsy. We believe that sentinel lymph-node biopsy should be avoided in cases of lymphoma.

[Conservative surgery in breast cancer: combination skin incision for a better cosmetic result]

The authors report a surgical procedure for lumpectomy combining both areolar and radial skin incision for cancer localized in the inferior, or at the junction of the superior and inferior part of the breast. The skin incision have an "amphore-like" appearance. It allows an easy mammoplasty with all cancerologic securities.

Les métastases intrathyroïdiennes du cancer du rein à cellules claires : présentation de sept cas et revue de la littérature

PURPOSE

The aim of this study was to retrospectively report clinical manifestations, type of treatment, survival rate of thyroid metastases from renal carcinoma.

PATIENTS AND METHODS

Seven patients were retrospectively collected from files of different Burgundy's hospitals. All renal and thyroid gland specimens were controlled by the anatomopathologist.

RESULTS

Tumors occurred in four women and three men (mean age: 66 years). Symptoms were generally a solitary mass. The metastatic tumor to the thyroid gland was the initial presentation of renal carcinoma in one case. In the other cases, patients had documented previous evidence of renal carcinoma as remotely 8.1 years before the thyroid metastases. Thyroglobulin immunohistochemistry was always negative in the foci of metastatic renal carcinoma. All patients had surgical resection of there metastasis. The majority of patients died with disseminated malignancies (mean: 38.1 months after there thyroid resection). Three patients are still alive, one after a complementary pancreatic resection for a secondary pancreatic metastasis and one other with cervical and mediastinal lymph node recurrence.

CONCLUSIONS

Surgical treatment of the metastatic disease is suggested, as this may prolonged patient survival.

Prélèvements anatomopathologiques en cancérologie : règles de bonnes pratiques au bloc opératoire

Concerning good practice for the management of histological cancer specimen, the main recommendations concern: (1) the quality of transmission in information between professionals; (2) the necessity of fresh, unfractionated, oriented surgical samples; (3) the importance of an appropriate storage condition for samples collected for extemporaneous examination, freezing or cell culture; (4) the quality of the deep freezer at temperatures of -80 degrees C or liquid nitrogen for frozen samples storage; (5) the importance of fixing tissues shortly after sample collection in buffered Formal solution in order to prevent cell lysis.

[Role of microbiopsy in diagnostic and therapeutic approach of mammary suspect microcalcification]

PURPOSE

To determine the sensibility, the specificity, the positive and negative predictive values of microcalcifications detection by core needle biopsy and intra-operative pathologic examination.

MATERIALS AND METHODS

A hundred and one patients (between 1998 and 1999) were investigated in this retrospective study. The initial presentation was breast microcalcifications without palpable tumour. The mean age of patients was 55 (34-79) years. Mammography was performed in 3 standard projections. All suspect microcalcifications were recommended for surgical excision. In the others cases, 5 core biopsies were taken of the lesion. Needle guidance was accomplished by means of either dedicated stereotaxic device or ultrasound equipment. All biopsies were performed with a biopsy device fitted with 14 G needles. The mean follow-up period was 3 years.

RESULTS

Clinical or surgical follow-up was available in 101 lesions. Only 4 benign lesions did not have surgery. The 97 remaining were subsequently excised. Pathologic study showed cancer in 38 (39%) lesions, carcinoma in-situ in 14 lesions, and benign disease in 45 lesions. There was 1 false-negative biopsy. The specificity and sensitivity of percutaneous biopsy diagnosis were 73,6 and 93,7% respectively. Intra-operative pathologic diagnoses were concordant in 77% of 30 cases. Discordance occurred in 2 cases of atypical hyperplasia with a single false-negative result for a carcinoma that led to an additional surgical procedure. Positive and negative predictive values of intra-operative pathologic diagnosis were 82 and 100% respectively.

CONCLUSION

Needle biopsy findings are accurate and allow definitive therapeutic surgery, including mastectomy.

[The sentinal node: the Dijon experience]

OBJECTIVES

The goal of this study was to evaluate the technical feasibility of sentinel node biopsy in breast cancer and its capacity to predict axillary node status.

MATERIAL AND METHODS

Between February 2000 and June 2001, 70 patients with invasive breast carcinomas referred to the cancer center of Dijon, underwent lymphatic mapping (patent blue dye and lymphoscintigraphy with a gamma probe) and sentinel node biopsy followed by axillary clearance (Berg's level 1 and 2).

RESULTS

A sentinel node was identified in 94.26% of the patients. We noted 2 false negative sentinel lymph nodes. The sentinel lymph node was involved in 32.8% of the patients and was the only node involved in 14.2% of the patients.

CONCLUSION

This study confirms the feasibility of sentinal node mapping, emphasizing the advantage of using two methods (patent blue dye and gamma probe). A learning curve is required. This procedure is not adapted for tumors larger than 3 cm because of a greater risk of sentinel node involvement and the need for a complete procedure with an axillary clearance.

[Preparation for Patey incision in mastectomy: technique demonstration]

The authors report a technique of skin resection for mastectomy in order to allow secure, tension free closure using a suture upon the nipple.

Impact of UFT on tumoral TS and DPD levels in colorectal cancer

This was an open lable, pilot translational clinical pharmacology study of a brief (7 day) course of UFT, 300 mg/m2/day, in combination with leucovorin, 90 mg/day, in six patients with newly diagnosed advanced colorectal cancer. The primary objectives of the study were to examine the impact of this treatment course on the UFT targets which are thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD). The rate of tumoral TS inhibition after the 7-day UFT treatment sequence varied from 5% up to 31%. UFT treatment induced a constant and variable decrease in tumor DPD activity ranging from 13% to 60%. UFT treatment induced a constant increase in uracil concentrations both in plasma and tumors. FT, 5-FU and the metabolite fluoro-beta-alanine (FBAL) were found in plasma and tumors at variable concentrations; the highest drug concentrations were those of FBAL in plasma. The present translational clinical study provides data related to the in vivo pharmacological effects of UFT with a description of its impact on cellular targets.

Preoperative radiotherapy and surgery for endometrial carcinoma: prognostic significance of the sterilization of the specimen

INTRODUCTION

We report a retrospective study on the analysis of the operative specimen after preoperative radiotherapy for FIGO (1971) stage I or II endometrial carcinoma.

METHODS AND MATERIALS

From 1976 to 1996, 221 patients were treated with external radiotherapy (XRT) and/or low-dose-rate brachytherapy (BT) followed by surgery (S). Patients with cervical involvement (89 patients) or with high-grade tumors (49 patients) received XRT and BT. Patients stage FIGO Ia (89 patients) or with low-grade tumors (57 patients) received BT alone. Surgery was performed 5 to 6 weeks after irradiation.

RESULTS

The mean follow-up is 78 months (12-216). The 5-year survival was 90% for FIGO Ia, 80% for FIGO Ib, and 84% for FIGO II (p = 0.51). According to the differentiation, 5-year survival was 87% for grade 1, 84% for grade 2, 84% for grade 3 (p = 0.10). Grade 3 complications were registered in 2% (no grade 4). The tumors were sterilized in 37 patients (17%), sterilized but with dystrophic glands in 34 patients (16%), only modified and altered in 21 patients (9.5%), with viable cells in 56 patients (26%). After preoperative radiotherapy, 37/148 specimens were sterilized (25%), 14/74 after brachytherapy and surgery (19%), 23/74 after external radiotherapy-brachytherapy and surgery (31%). According to the response of the specimen, 5-year survival was 87% when the tumor was sterilized, 96% when altered glands were present, 85% when modified, and 76% if residual tumor with viable cells was identified (p = 0.043).

CONCLUSION

Preoperative radiotherapy followed by surgery is a safe and effective treatment of FIGO stage I or II endometrial carcinomas. BT with two uterine tubes seems to be of interest in the contribution of the treatment of the uterus to sterilize the specimen. The analysis of this new prognostic factor remains important to select a population with worst prognosis.

Conservative management of rectal adenocarcinoma by radiotherapy

PURPOSE

The aim of this study was to analyze the experience of Centre GF Leclerc for conservative and curative treatment by radiotherapy of low rectal cancer.

PATIENTS AND METHODS

A total of 151 patients received radiotherapy alone for rectal adenocarcinoma with curative intent. They were clinically staged according to size (T1 < 3 cm, and T2 > 3 cm) and depth of infiltration (A=superficial, and B=impaired mobility and T3 fixed). Over the past 6 years, rectal ultrasound (US) has been used systematically, compared with computed tomographic scan and magnetic resonance imaging when needed. Intracavitary contact X ray was given to 129 patients (69%), and brachytherapy in 45 of 151. External radiotherapy was used in 34 cases (22.5%).

RESULTS

Complete response was obtained in 93%. Local failures were observed in 50 cases (28%); two occurred in pelvic nodes after intracavitary X rays. Size (tumors > 3 cm) and alteration of mobility significantly influenced the rate of local failure (p=0.009 and 0.007). The addition of external radiotherapy in patients with poor prognostic factors improved the local control rate. A total of 39 patients with recurrence were amenable to salvage surgery. After salvage treatment, the local control rate was 82% with unlimited follow-up. The 5-year actuarial survival rate was 57%, with a specific survival of 66%. There was no difference in local control or survival according to differentiation of the tumors and distance between anal margin and the inferior level of the lesion. Severe late effect (grade 3) was 3.8%. The sphincter preservation was obtained in 104 of 124 cases (84%). The sphincter function was judged to normal in 102 of 104 patients (98%).

CONCLUSION

Intracavitary contact X ray is the treatment of choice for clinical Stage T1A rectal tumors. External radiotherapy significantly improved the results of treatment of tumors > 3 cm. Clinical staging and transrectal ultrasound allows a safe selection of indications. Radiotherapy alone may be proposed for selected cases as an alternative to mutilating surgery for small rectal adenocarcinoma.

[Cisplatin, 5-FU and preoperative radiotherapy in esophageal epidermoid cancer. Multicenter phase II FFCD 8804 study]

OBJECTIVES

The aim of this study was to analyze the efficacy and tolerance of preoperative radiochemotherapy in esophageal squamous cell carcinoma. Patterns of recurrence and prognostic factors were also studied.

PATIENTS AND METHODS

This multicentric phase II trial included patients deemed operable. Preoperative treatment associated 5-FU 800 mg/m2/d by continuous infusion, cisplatin 20 mg/m2/d and radiotherapy 3 Gy/d D 1-5 and D 22-26. Resection was planned 50 to 60 days after the beginning of therapy.

RESULTS

Seventeen centers accrued 96 patients, mean age 55.4 years. According to UICC 1978 classification: stage I 13%, stage II 53% and stage III 30%. Mean follow-up was 73 months. Pre-operative treatment was delivered at full dose in half of the patients. Ten percent of the patients did not receive the second cycle. Toxicity reached grade 3 in 23% and grade 4 in 7% of the patients. Two preoperative deaths occurred. Curative resection was performed in 82% of the patients. Operative mortality was 9%. tumors were sterilized on the operative specimen in 20% of the patients and microscopic remnants were observed in 13%. Preoperative clinical work-up overestimated histologic response in 10% of the cases underestimated it in 29%. After 2 years, a recurrence was observed in 56% of the patients: loco-regional in 30%, metastases in 19% and both in 7%. Median survival was 17 months and survival rates were 58% at 1 year and 25% at 5 years. Four prognostic factors influenced survival in multivariate analysis (Cox model): hematological toxicity grade 3 or 4, no complete response, circumferential extension > 2/3 and nodes visible on CT-scan. Factors positively influencing complete response were in multivariate analysis: a fungating tumor, weight loss < 8% and a full dose preoperative treatment.

CONCLUSION

In this study, preoperative treatment associating 5-FU-cisplatin and radiotherapy allowed a high resectability rate, with one third of patients achieving complete or nearly complete histologic response. A randomized study is warranted to know whether this combined treatment is better than surgery alone.

Preoperative radiotherapy in stage I/II endometrial adenocarcinoma

From 1972 to 1993, 170 patients received preoperative radiotherapy followed, 5-6 weeks later, by total extrafascial hysterectomy with bilateral salpingo-oophorectomy without lymphadenectomy. Eighty-three patients with good prognostic factors (low grade tumour and no cervical involvement) received low dose rate utero vaginal brachytherapy alone before surgery (Group 1). Eighty-seven patients with poor prognostic factors (high grade tumors and/or cervical involvement) received external radiotherapy to 40 Gy and low dose rate brachytherapy before surgery (Group 2). A single vaginal failure was observed (0.6%). The overall pelvic failure rate was 2.3% (four patients) including two cases with pelvic recurrence and metastases. Three of the four pelvic failures occurred in Group 1. Using the 1971 FIGO clinical staging, 5-year disease-free survival was 82% in Stage Ia, 79% in Stage Ib, and 81% in Stage II (P = 0.36). Five-year disease-free survival was 86% in Grade 1, 76% in Grade 2, and 83% in Grade 3 (P = 0.20). Five-year overall survival was 83% in Stage Ia, 79% in Stage Ib, and 83% in Stage II (P = 0.78). Five-year overall survival was 88% in Grade 1, 77% in Grade 2,83% in Grade 3 (P = 0.27). Complications were recorded with the French-Italian syllabus. Grade 2 complications occurred in 12 cases (7%), Grade 3 in five cases (3%). The lack of correlation between classical risk factors (stage, grade) and disease outcome suggests that preoperative radiotherapy strategies should be preferred when such factors can be identified before surgery.

[Gastroduodenal arterial aneurysm and chronic pancreatitis. A case and review of the literature]

A case of pseudoaneurysm of the gastroduodenal artery due to chronic pancreatitis is reported. Pancreatitis causing splanchnic arterial aneurysm is more likely to affect the splenic artery than the gastroduodenal artery. Ten percent of cases of chronic pancreatitis are associated with splanchnic aneurysm. Hemorrhage occurs in 50% of cases. Color Doppler ultrasound is the best diagnostic tool, indicating the need for coeliac arteriography. In our case report, transcatheter embolization was performed with stainless steel coils and the pseudoaneurysm was successfully occluded.

Cytogenetic experience in prenatal fra(X) detection on amniotic fluid cultures

Since 1987, we have had experience with 13 prenatal diagnoses of 11 women at risk for the fragile X syndrome by cytogenetic studies on amniotic fluid cultures. The induction method included TC 199 medium and methotrexate. Results were obtained in all cases. Ten were males and three were prenatally diagnosed as being affected. Three were females and none of them was fra(X)-positive. Results were confirmed in 10/13 cases. In these cases, we had neither false-positive nor false-negative results.

Association of t(15;17) and t(8;21) in the initial phase of an acute promyelocytic leukemia

Two clones were observed at the initial phase of an acute myelogenous leukemia (AML): 46,XX,t(15;17) and 46,XX,t(8;21),t(15;17). Clinical, immunologic, and morphologic findings were in favor of expression of both chromosomal anomalies. Relapse occurred after 12 months of complete remission with typical acute promyelocytic leukemia (APL) syndrome when t(15;17) alone was then most predominant.

Correlations between cytogenetics and morphology in myelodysplastic syndromes

In order to detect possible relationships between cytogenetic abnormalities and morphologic features in myelodysplastic syndromes (MDS), 48 patients with MDS were investigated. Clonal cytogenetic abnormalities were present in bone marrow cells from 27 patients (56%). The most frequent single anomaly was del (5 q) (10 cases), followed by monosomy 7 (3 cases), trisomy 8 (3 cases) and del (20 q) (2 cases). Complex anomalies were present in 6 patients. Morphologically, according to the French-American-British (FAB) classification: 17 cases were considered as refractory anemia (RA), 17 as RA with excess of blasts (RAEB), 2 as RAEB in transformation, 2 as acquired idiopathic sideroblastic anemia and 10 as chronic myelomonocytic leukemia. With regard to the FAB classification, del (5 q) was often associated with RA and complex cytogenetic anomalies with RAEB. When myelodysplasia was studied in individual myeloid lineages, del (5 q) was associated with hypolobulated megakaryocytes, monosomy 7 with micromegakaryocytes and complex chromosomal anomalies with the association of two or more features of dysmegakaryocytopoiesis. Del (11 q) was associated with increased iron storage and del (20 q) with marked dyserythropoiesis. No correlation was observed between cytogenetic anomalies and features of dysgranulocytopoiesis.

Partial chimerism after T-cell-depleted allogeneic bone marrow transplantation in leukemic HLA-matched patients: a cytogenetic documentation

We evaluated serially by cytogenetics the blood and marrow chimerism of 38 leukemic recipients of HLA-matched bone marrow transplants (BMT) who were prepared by high doses of alkylating agents and fractionated total-body irradiation (2.2 Gy X 5). Donor or host mitoses were identified by examination of sex chromosomes in 32 patients or by evaluation of the polymorphism of other chromosomes after specific banding in six patients. Twenty-four patients were recipients of untreated BMT, and 14 were recipients of T-cell-depleted BMT. In the 24 patients who received untreated BMT, all showed successful engraftment, and only three had a transient mixed chimera. In the 14 recipients of T-cell-depleted BMTs, four rejected their grafts, and seven had mixed chimeras; these mixed chimeras were more frequent in blood lymphocytes than in marrow cells and could be detected up to 26 months after BMT. This high frequency of partial chimerism after T-cell-depleted BMT by comparison with a control group suggests that the donor's T cells play an important role in the eradication of host residual hematopoiesis after allogeneic BMT.

[The contribution of cytogenetics to the evaluation of residual disease in malignant hemopathies]

Autologous bone marrow transplantation is now a major tool in the treatment of human leukemias and lymphomas. Evaluation of residual disease by standard cytological methods is difficult. Cytogenetics provide clonal markers which are specific features of leukemic cells. Detection of minimal disease by chromosomal methods is possible in acute leukemias, it requires karyotyping of a few hundred metaphases from a short term culture. A preselection of the material to be examined will improve the degree of sensitivity of the method.

[t(Y; 15) translocation in a fertile male, detected at the time of amniocentesis]

Cytogenetic studies on a phenotypically normal fertile male revealed an unbalanced Y; 15 translocation. His wife referred for a prenatal diagnosis because of maternal age. The foetus was male and carried the same translocation.