The inverse square law: A basic principle in brachytherapy

The purpose of this article is to remind the importance of the inverse square law in radiotherapy and especially in brachytherapy. Indeed, beyond the impact in radiation therapy with high energy beam, there is the use of radionuclides and low energy photons with short FSD where it is still more important. Comparisons between Iridium Brachytherapy and low energy X-rays brachytherapy show equivalent dose distributions in the first few centimeters. If the inverse square law is not the only element influencing the dose distributions calculations, it must not be forgotten. And it is playing a major role in brachytherapy with short FSD (<6cm).

Aims of combined modality therapy in rectal cancer (M0)

OPTIMIZING THE COST/BENEFIT RATIO OF TREATMENT: Evidence Based The aim of a cancer treatment is always to achieve the maximum of cure rate with a minimum of toxicity and best quality of life at an acceptable cost for the society. It is always a multifactorial challenge depending on the patient, the tumor, the doctor, and the society cultural and financial backgrounds. The goal is to find the best cost/benefit ratio between all possible strategies in agreement with a well-informed patient. In rectal cancer (M0) surgery is the cornerstone of treatment. Combined modality therapies aim at optimizing the cost/benefit ratio of possible strategies and only randomized trials can bring strong evidence regarding their results and recommendations. LESSONS FROM RANDOMIZED TRIALS: quite modest During the past decades many phase III trials have shown that: (1) neoadjuvant treatment even with "TME" surgery was better than adjuvant, (2) chemoradiotherapy (CRT) was better than RT alone, (3) long course CRT was probably more efficient (in terms of ypCR) than short course (25/5), and (4) capecitabine was as efficient as 5 FU but oxaliplatin was not adding benefit. Overall, the gains of nCRT remain modest and it is mainly a reduction in local relapse not exceeding 5 %, but no benefit in survival and neither in sphincter saving surgery has been proven. The way forwards organ preservation in case of CCR. Local control: can probably be improved for T4 tumors by RT dose escalation. Survival: can be increased by innovative medical treatment either before or after surgery.

TOXICITY

may be reduced by a less aggressive treatment in elderly. Conservative treatment: A new field of clinical research is to achieve "organ preservation" (and not only sphincter saving). To modify the surgical approach and preserve the whole rectum, neoadjuvant treatment must achieve safely a clinical complete response. As rectal adenocarcinoma is a relatively radioresistant tumor endocavitary irradiation (contact X-Ray) is a promising safe approach and this hypothesis will be addressed by the OPERA randomized trial.

What is the clinical benefit of preoperative chemoradiotherapy with 5FU/leucovorin for T3-4 rectal cancer in a pooled analysis of EORTC 22921 and FFCD 9203 trials: surrogacy in question?

BACKGROUND

Two phase III trials of neoadjuvant treatment in T3-4 rectal cancer established that adding chemotherapy (CRT) to radiotherapy (RT) improves pathological complete response (pCR) and local control (LC). We combined trials to assess the clinical benefit of CRT on overall (OS) and progression free survival (PFS) and to explore the surrogacy of pCR and LC.

PATIENTS AND METHODS

Individual patient data from European Organisation for Research and Treatment of Cancer (EORTC) 22921 (1011 patients) and FFCD 9203 (756 patients) were pooled. Meta-analysis methodology was used to compare neoadjuvant CRT to RT for OS, PFS LC and distant progression (DP). Weighted linear regression was used to estimate trial-level association (surrogacy R(2)) between treatment effects on candidate surrogate (pCR, LC, DP) and OS.

RESULTS

The median follow-up was 5.6 years. Compared to RT (881 pts), CRT (886 pts) did not prolong OS, DP or PFS. The 5-y OS-rate was 66.3% with CRT versus 65.9% in RT (hazard ratios (HR) = 1.04 {0.88-1.21}). CRT significantly improved LC (HR = 0.54, 95%confidence interval (CI): 0.41-0.72). PFS was validated as surrogate for OS with R(2) = 0.88. Neoadjuvant treatment effects on LC (R(2) = 0.17) or DP (R(2) = 0.31) did not predict effects on OS.

CONCLUSION

Preoperative CRT does not prolong OS or PFS. pCR or LC do not qualify as surrogate for PFS or OS while PFS is surrogate. Phase III trials should use OS or PFS as primary endpoint.

Influence of age on chemoradiotherapy outcome in patients with rectal cancer: Exploratory analysis from the phase III study ACCORD 12/0405 PRODIGE 2

550

Background: Preoperative radiochemotherapy (RCT) is the standard of care for patients (pts) with locally advanced rectal adenocarcinoma. However elderly pts may have an increased risk of adverse events after combined modality treatment. The randomized trial ACCORD 12/0405 PRODIGE 2 compared 5 weeks of treatment with radiotherapy 45 Gy/25 fractions (f) with concurrent capecitabine 800 mg/m² twice daily 5 days per week (Cap 45) or radiotherapy 50 Gy/25 f with capecitabine 800 mg/m2 twice daily, 5 days per week and oxaliplatin 50 mg/m2 once weekly (Capox 50), results of efficacy (complete pathologic response) were not different between the two arms. We analyzed the results of RCT according to pts age.

Methods: All eligible pts (n=584) were included in this exploratory analysis. Pts were divided in 2 groups: <70 y and ≥70 y. Toxicity and tumor regression scores were compared between the 2 groups.

Results: 442 pts were <70 y and 142 were ≥70 y. Pts characteristics were well balanced between groups (gender, ECOG performance status, primary tumor, histology). Tolerance was worse in pts ≥70 y as shown in the table. Surgical procedures were not different between the 2 groups. Results on histological response were similar between the 2 groups: complete pathologic response was 16.9% (95% CI 13.1 to 20.2%) for pts <70 y and 14.7% (95% CI 9.2 to 21.8%) for pts ≥70 y, (p=0.55) and rates of R0 surgery for pts < 70 y and pts ≥ 70 y were respectively: 90.6% and 88.2%, (p=0.54).

Conclusions: As tolerance of elderly pts treated with preoperative RTCT is worse than in younger pts, appropriate therapeutic schedule are warranted for these pts.

[Table: see text]

Whither Papillon? — Future Directions for Contact Radiotherapy in Rectal Cancer

Although contact radiotherapy was developed 70 years ago, and is highly effective with cure rates of over 90% for early rectal cancer, there are few centres that offer this treatment today. One reason is the lack of replacement of ageing contact X-ray machines, many of which are now over 30 years old. To address this problem, the International Contact Radiotherapy Evaluation (ICONE) group was formed at a meeting in Liverpool in 2005 with the aim of developing a new contact X-ray unit and to establish clinical protocols that would enable the new machine to safely engage in the treatment of rectal cancer. As a result of these efforts, a European company is starting production of the new Papillon RT-50 machine, which will be available shortly. In addition, the ICONE group is planning an observational study on contact X-ray and transanal endoscopic microsurgery (CONTEM) for curative treatment of rectal cancer. This protocol will ensure standardised diagnostic procedures, patient selection and treatment in centres across the world and the data will be collected prospectively for analysis and audit. It is hoped that the CONTEM trial will provide the scientific evidence that is needed to obtain a broader acceptance of local contact radiotherapy as a treatment option for selected cases with early stage rectal cancer.

French experience with contact X-ray endocavitary radiation for early rectal cancer

This paper is an overview of the French experience with contact X-ray radiation for rectal cancer. The analysis was mainly carried out on 50 years of experience in Lyon or since 1980 in the Centre Hospitalier Universitaire Lyon Sud. The results obtained in Dijon and Nancy are also reported. In early rectal cancer, contact X-ray radiation can play an important role in three different situations: (1) small T1 less than 2 cm: adjuvant contact X-ray radiotherapy after local excision; (2) T2 N0 or large T1: first-line contact X-ray radiotherapy combined with external beam radiotherapy (+/- chemotherapy) followed by surgery (anterior resection or local excision); (3) early T3 N0 in frail patients: the same approach as for T2 N0 with, in case of clinical complete response, local excision or follow-up.

Radiotherapy in the conservative treatment of rectal cancer. Evidence-based medicine and opinion

BACKGROUND AND PURPOSE

This lecture is given on behalf of my former Lyon Sud Radiotherapy department (Dr P. Romestaing) and of the Radiotherapy Department of Centre Antoine-Lacassagne in Nice (Dr A. Courdi) without which it would have been impossible to produce any original clinical data. The major benefit from radiotherapy (RXT) in oncology can be summarized with 3 'C': cure-cost effectiveness-conservative treatment.

PATIENTS AND METHODS

Rectal cancer illustrates the hypothesis that radiotherapy can increase the chance of conservative treatment (with sphincter preservation SP). Sphincter preservation is a complex process, and only randomized trials can be used to see if preoperative treatment can increase SP.

RESULTS

Different phase III trials have shown that: preoperative RXT is superior to postop RX (local control--toxicity--SP), preoperative RXT with immediate surgery does not increase SP, preoperative RXT with delayed surgery increases SP, concurrent chemotherapy with RXT has not yet proven to increase SP, important dose escalation (90 Gy) with contact X-ray RXT increases complete clinical tumor response and SP.

CONCLUSIONS

The surgeon is the key person for the cure of rectal cancer and mainly responsible for the decision of sphincter preservation. The experience gained with contact X-ray therapy stresses the importance of a complete clinical tumor response before surgery to increase the chance of sphincter preservation. 'High dose small volume' RXT is a key factor to achieve such a complete clinical tumor response.

Partial breast irradiation: revolution or evolution?

INTRODUCTION

It is well established that there is no significant difference in terms of overall survival between mastectomy and radio-surgical conservative treatment (RSCT). Ten to fifteen years have been needed to change from the "standard" to the "new" breast cancer treatment. At the end of the 1990s, a few authors published preliminary results of phase II trials using partial breast irradiation (PBI) as sole post-operative treatment based on interstitial low or high dose rate brachytherapy techniques. Currently, phase III randomized trials comparing whole breast irradiation versus PBI are ongoing in the USA and in EU.

MATERIALS AND METHODS

The authors reviewed the literature regarding issues in the irradiation of breast cancer and the potential role of PBI to prevent local recurrence in the ipsilateral breast. Furthermore, potential advantages of PBI were discussed as well as the limits of such a procedure. Finally, we tried to determine the characteristics of a subgroup of patients who would receive benefit from this radiation technique.

RESULTS

Phase II and III trials have been analyzed concerning feasibility, efficacy and toxicity. PBI may be delivered through low or high dose rate brachytherapy or intraoperative/external beam radiation therapy. PBI satisfies the control quality criteria. The majority of the teams provide PBI recurrence rates lower than 5% (0-4.4%) with a median follow-up varying between 8 and 72 months, and associated with cosmetic results comparable to those achieved with conventional external beam.

CONCLUSION

RSCT does not replace mastectomy; mastectomy and RSCT are used together to treat different subgroups of patients. PBI furnished encouraging preliminary results in terms of local control and cosmetic results. However, caution in interpreting the results is required along with longer follow-up. PBI should not replace CT, but could be considered as a new therapeutic strategy for breast cancer dedicated to a very well defined subgroup of patients with a low risk of local recurrence.

[Preliminary results of the assessment of intensity modulated radiotherapy (IMRT) for prostatic and head and neck tumors (STIC 2001)]

INTRODUCTION

Between May 2002 and May 2004, eight French comprehensive cancer centres did a prospective nonrandomized study including 200 patients, 100 with cancer of the prostate and 100 with head and neck cancers. Half of each patient group was treated by IMRT and the others by RTC 3D. This clinical study was associated with an economic study and a physics study. We report here the first results.

PATIENTS AND METHODS

For the clinical study, the analysis of the data of the first 88 patients irradiated for a prostatic cancer shows that 39 received RTC and 49 IMRT with a mean dose of 78 Gy at the ICRU point at 2 Gy per fraction. For H&N tumours, the preliminary analysis was done on the 87 first patients with a mean follow-up of 11.5 months (2 to 25 months) and a median of 8.4 months for the IMRT groups and 13.2 months for the RTC group. The economic study was done on the first 157 patients included during the first 18 months: 71 treated by RTC (35 for H&N and 36 for prostate) and 86 treated by IMRT (38 for H&N and 48 for prostate). The assessment of the direct costs was realized by a micro-costing technique. The physical study compared dose distributions for both techniques and has created quality control recommendations.

RESULTS

Clinical studies of the acute reactions do not show any difference between groups, but we want to point out the short follow-up and the relatively high dose delivered to cancers of the prostate. The physics study demonstrates that IMRT is technically feasible in good clinical conditions with high quality assurance, a good reproducibility and precision. Dosimetric data show that IMRT could certainly spare organs at risk more than RTC for H&N tumours. The direct costs of "routine" treatments for H&N tumours were 4922 euros for IMRT versus 1899 euros for RTC and for the prostatic cancers 4911 euros for IMRT versus 2357 for RTC.

Radiochemotherapy in rectal cancer: the role of oxaliplatin

Radiation therapy is well established in the treatment of early and locally advanced rectal cancer, where it has been used in both the pre-operative and postoperative settings. Pre-operatively, radiation therapy has been shown in a series of studies culminating in the Dutch total mesorectal excision (TME) study to significantly reduce the rate of local recurrence at 2 years. However, the overall rate of survival was not improved in this study because radiotherapy failed to reduce the incidence of distant metastases. Chemotherapy, however, may reduce distant metastatic spread, as well as increasing the rate of R0 resectability and sphincter-saving surgery when used in combination with radiotherapy in the neoadjuvant setting. Oxaliplatin is a prime candidate for radiochemotherapy in rectal cancer because it frequently has large and rapid cytoreductive effects in colorectal malignancies and has been shown in vitro and preclinical models to be radiosensitizing. In an Italian phase I/II study, weekly oxaliplatin combined with standard infusional 5-FU and pre-operative radiotherapy has shown low toxicity and promising antitumour activity. These encouraging results are now being followed up in a more extensive trials programme. A randomized trial comparing this regimen with standard infusional FUra and radiotherapy (STAR, Studio nazonaleTerapia neoAdiuvante Retto [National Study on Neoadjuvant Treatment of Rectal cancer]) is being launched in Italy. A new phase II study, CORE (Capecitabine, Oxaliplatin, Radiotherapy and Excision), is now in development in Europe and will use a similar weekly treatment regimen with an oral fluropyrimidine in place of infusional FUra, and a number of further oxaliplatin-based radiochemotherapy studies in rectal cancer are planned or in progress. In summary, radiochemotherapy appears to have the potential to significantly improve clinical outcomes in rectal cancer, and oxaliplatin-based treatment is proving central to its ongoing development.

Surgical management of retroperitoneal sarcomas associated with external and intraoperative electron beam radiotherapy

AIMS

To report outcomes of adults with retroperitoneal sarcoma (RS) treated by surgery, external beam radiotherapy (EBRT) and intraoperative electron beam radiotherapy (IORT).

METHODS

From July 1988 to February 2001; 24 patients with primary and recurrent RS were diagnosed and treated. The median dose and energy of IORT delivered was 15 Gy/9meV. EBRT dose varies between 45-50 Gy.

RESULTS

There were five primary and 19 recurrent tumours. One primary and five recurrent tumours underwent R0 resection. There were 12 liposarcomas and 19 grade I tumours; 13 patients developed local recurrence and three developed distant metastases.Twenty-two patients received IORT associated with EBRT: 11 developed recurrences. Six patients developed Neurotoxicity (4 grade II and 2 grade III). Disease free survival and overall survival at 5 years was 28 and 56% respectively.

CONCLUSIONS

EBRT with IORT treatment is a promising technique for local control. Lower recurrence rates are associated with radical (R0) surgical procedures.

Breast Cancer in Elderly Women: is Partial Breast Irradiation a Good Alternative?

BACKGROUND

Approximately half of all breast cancer occurs after age 65. Several aspects for the treatment of early breast cancer may be influenced by patient age, including postoperative radiation therapy (RT), in order to prevent the risk of local recurrence (LR). Postoperative adjuvant RT, improving the chances of local control, is not always completed because of comorbidity-associated factors. Does an alternative exist between a 5-week radiotherapy regime and no irradiation after breast conservative surgery without burdening the overall therapeutic management?

METHODS

The authors review the literature regarding age-specific issues in the irradiation of breast cancer and the potential role of a partial breast irradiation (PBI) to prevent LR in the ipsilateral breast.

RESULTS

Phase II and III trials have been analyzed for feasibility, efficacy and toxicity. PBI may be delivered with low or high dose rate brachytherapy and intra operative, or external beam radiation therapy. PBI satisfies the control quality criteria. The majority of the teams provide PBI recurrence rates lower than 5% (0-4.4%) with a median follow-up varying between 8 and 72 months, associated with cosmetic results comparable to those achieved with conventional external beam.

CONCLUSIONS

Breast cancer in elderly women represents a medical and economical problem. The recommended conservative treatment includes RT for 50 Gy over 5 weeks. Some subgroups of patients did not receive radiotherapy because of comorbidity-associated factors or more favorable tumor biology. PBI seems to be an acceptable alternative to adjuvant RT over 5 weeks and no irradiation. The evaluation of toxicity and efficacy, especially in terms of local control, is necessary and large multicentric phase III trials comparing the two irradiation approaches are needed, including quality of life, economic considerations and longer follow-up.

Long-term results of the Lyons R90-01 randomized trial of preoperative radiotherapy with delayed surgery and its effect on sphincter-saving surgery in rectal cancer

Delayed surgery does not reduce local recurrance or improve survival

Ceramide induces activation of the mitochondrial/caspases pathway in Jurkat and SCC61 cells sensitive to gamma-radiation but activation of this sequence is defective in radioresistant SQ20B cells

PURPOSE

To clarify the molecular mechanisms leading to radiation-induced apoptosis or resistance, the kinetics (1-48 h) and sequence of events triggered in response to 10 Gy irradiation were investigated in three cell lines displaying a gradient of sensitivity to 7-rays.

MATERIALS AND METHODS

Ceramide levels were measured by high performance liquid chromatography (HPLC). Mitochondrial function was evaluated in terms of transmembrane potential (delta(psi)m), reactive oxygen species (ROS) and glutathione levels analysed by flow cytometry or HPLC. Caspase activation was assessed by immunoblotting, and apoptosis by flow cytometry.

RESULTS

In Jurkat radiosensitive cells and SCC61 adherent cells with intermediate radiosensitivity, the degree of delayed ceramide release was directly related to their propensity to undergo apoptosis. Transduction of the death signal was mediated by a drop in delta(psi)m and glutathione levels, ROS accumulation and activation of effector caspases. Experiments conducted with caspase inhibitors, bongkrekic acid, or DL-PDMP indicated that ceramide triggers mitochondrial collapse, followed by the activation of caspases-9, -8 and -3, and poly(ADP-ribose)polymerase cleavage. In SQ20B radioresistant cells, gamma-radiation did not induce ceramide generation or subsequent activation of the mitochondrial/caspase apoptotic pathway.

CONCLUSIONS

Ceramide appears to be a determining factor in the commitment phase of radiation-induced apoptosis. When ceramide is not generated, the whole pathway is ineffective and resistance to apoptosis may result.

Redifferentiation therapy in brain tumors: long-lasting complete regression of glioblastomas and an anaplastic astrocytoma under long term 1-alpha-hydroxycholecalciferol

PURPOSE

Classical and new therapies in anaplastic astrocytomas and glioblastomas do not yield sufficient results. Agents able to redifferentiate neoplastic cells in vitro are known. We proposed alfacalcidol, a vitamin D analog able to bind to nuclear receptors regulating mitotic activity, in the treatment of malignant gliomas.

PATIENTS AND METHODS

Patients with glioblastomas and anaplastic astrocytomas were enrolled in a phase II trial involving surgery or biopsy, radiotherapy (64 Gy), chemotherapy with VM26-CCNU or fotemustine, and alfacalcidol at the daily dose of 0.04 microg/kg. MRI took place every 6 months.

RESULTS

Eleven patients were included and completed the study. The series involved 10 glioblastomas and 1 anaplastic astrocytoma. Three patients out of 11 patients (27%), 2 glioblastomas and 1 astrocytoma grade III, exhibited a particular response, consisting in the progressive regression of the radiological lesion, with a decrease of the gadolinium-enhanced area. Simultaneously, the patients showed a complete clinical remission, observed respectively for 7, 5 and 4 years. In the series of 10 patients with glioblastomas, 2 cases showed this response; after 4 years, 2 of 10 patients with glioblastomas (20%) were alive; the median survival time is 21 months. Normal or subnormal calcemia was observed, at the dose proposed, so that no interruption of the drug was necessary.

CONCLUSIONS

Alfacalcidol, an in vitro agent of redifferentiation, is safe and seems able to induce in some patients, in synergy with classical surgery-radiotherapy-chemotherapy treatments, a particular progressive and durable regression of the tumor. The responders might represent about 20% of malignant gliomas.

Management of inguinal lymph node metastases in patients with carcinoma of the anal canal: experience in a series of 270 patients treated in Lyon and review of the literature

BACKGROUND

The authors performed a specific analysis of the clinical significance of inguinal lymph nodes metastases in patients with anal canal carcinoma (ACC).

METHODS

A retrospective analysis was conducted of 270 patients who were treated in Lyon between 1980 and 1996 with radiotherapy with curative intent for ACC: No elective irradiation of clinically normal inguinal areas was performed. Patients with metastatic inguinal lymph nodes were treated with inguinal dissection and postoperative irradiation with a dose of 50 grays over 5 weeks. Concomitant chemoradiation, usually with a regimen of fluorouracil and cisplatinum, was given to 159 patients.

RESULTS

The median follow-up for the whole series was 72 months. Synchronous inguinal metastases were observed in 10% of patients (n = 27; the rate was 16% for patients with T3--T4 lesions), and the 5-year overall survival rate was 54.4%. Metachronous inguinal metastases were seen in 19 patients (7.8%), and the 5-year overall survival rate of these patients was 41.4%. An original finding was that, when the primary tumor clearly was located on a single lateral side of the anal canal, the inguinal lymphatic metastases was always homolateral to it (36 of 36 synchronous plus metachronous tumors).

CONCLUSIONS

The data from this series of patients and a review of the literature are in favor of a selective approach in the management of inguinal lymph node involvement for patients with ACC, depending on the disease stage and the location of the primary tumors.

Management of inguinal lymph node metastases in patients with carcinoma of the anal canal: experience in a series of 270 patients treated in Lyon and review of the literature

BACKGROUND

The authors performed a specific analysis of the clinical significance of inguinal lymph nodes metastases in patients with anal canal carcinoma (ACC).

METHODS

A retrospective analysis was conducted of 270 patients who were treated in Lyon between 1980 and 1996 with radiotherapy with curative intent for ACC: No elective irradiation of clinically normal inguinal areas was performed. Patients with metastatic inguinal lymph nodes were treated with inguinal dissection and postoperative irradiation with a dose of 50 grays over 5 weeks. Concomitant chemoradiation, usually with a regimen of fluorouracil and cisplatinum, was given to 159 patients.

RESULTS

The median follow-up for the whole series was 72 months. Synchronous inguinal metastases were observed in 10% of patients (n = 27; the rate was 16% for patients with T3--T4 lesions), and the 5-year overall survival rate was 54.4%. Metachronous inguinal metastases were seen in 19 patients (7.8%), and the 5-year overall survival rate of these patients was 41.4%. An original finding was that, when the primary tumor clearly was located on a single lateral side of the anal canal, the inguinal lymphatic metastases was always homolateral to it (36 of 36 synchronous plus metachronous tumors).

CONCLUSIONS

The data from this series of patients and a review of the literature are in favor of a selective approach in the management of inguinal lymph node involvement for patients with ACC, depending on the disease stage and the location of the primary tumors.

Differential expression of growth factors in irradiated mouse testes

PURPOSE

By using as an experimental model the male mouse gonad, which contains both radiosensitive (germ) and radioresistant (somatic) cells, we have studied the growth factor (and/or receptor) expression of transforming growth factor-beta receptor (TGFbeta RI), stem cell factor (SCF), c-kit, Fas-L, Fas, tumor necrosis factor receptor (TNF R55), and leukemia inhibiting factor receptor (LIF-R) after local irradiation.

METHODS AND MATERIALS

Adult male mice were locally irradiated on the testes. Induction of apoptosis in the different testicular cell types following X-ray radiation was identified by the TdT-mediated dUTP Nick End Labeling (TUNEL) approach. Growth factor expression was evidenced by semiquantitative RT-PCR and Western blot analyses.

RESULTS

Apoptosis, identified through the TUNEL approach, occurred in radiosensitive testicular (premeotic) germ cells with the following kinetics: the number of apoptotic cells increased after 24 h (p < 0.001) and was maximal 48 h after a 2-Gy ionizing radiation (p < 0.001). Apoptotic cells were no longer observed 72 h after a 2-Gy irradiation. The number of apoptotic cells increased with the dose of irradiation (1-4 Gy). In the seminiferous tubules, the growth factor expression in premeiotic radiosensitive germ cells was modulated by irradiation. Indeed Fas, c-kit, and LIF-R expression, which occurs in (radiosensitive) germ cells, decreased 24 h after a 2-Gy irradiation, and the maximal decrease was observed with a 4-Gy irradiation. The decrease in Stra8 expression occurred earlier, at 4 h after a 2-Gy irradiation. In addition, a significant (p < 0.03) decrease in Stra8 mRNA levels was observed at the lowest dose used (0.5 Gy, 48 h). Moreover, concerning a growth factor receptor, such as TGFbeta RI, which is expressed both in radiosensitive and radioresistant cells, we observed a differential expression depending on the cell radiosensitivity after irradiation. Indeed, TGFbeta RI expression was increased after irradiation in interstitial radioresistant testicular cells in a dose- and time-dependent manner, while it decreased in seminiferous radiosensitive (germ cells) testicular cells. Such a differential expression between radioresistant and radiosensitive cells in TGFbeta RI levels was observed in terms of both mRNA and protein. In contrast, the growth factors specifically expressed in the somatic radioresistant (Sertoli) cells in the seminiferous tubules (SCF, Fas-L, TNF R55) were not affected by ionizing radiation (up to 4 Gy, 72 h).

CONCLUSION

Growth factor expression decreased in the radiosensitive testicular cells after irradiation. Such a decrease occurred before the detection of apoptosis using the TUNEL approach. TGFbeta RI mRNA levels decreased in the radiosensitive cells, whereas it increased in the radioresistant cells, suggesting that TGFbeta RI may represent a biomarker of the intrinsic radiosensitivity of cells.

Functional results of delayed coloanal anastomosis after preoperative radiotherapy for lower third rectal cancer

BACKGROUND

The aim of this study was to assess functional outcomes of patients who had a delayed coloanal anastomosis for a lower third rectal cancer after preoperative radiotherapy.

STUDY DESIGN

From January 1988 to December 1997, 35 patients with an adenocarcinoma of the lower third of the rectum received preoperative radiotherapy (45Gy) followed by a rectal resection, combining an abdominal and transanal approach. Colorectal resection was performed about 32 days after the end of the radiotherapy. The distal colon stump was pulled through the anal canal. On postoperative day 5 the colonic stump was resected and a direct coloanal anastomosis performed without colostomia diversion.

RESULTS

There was no mortality. There was no leakage. One patient had a pelvic abscess. One patient had a necrosis of the left colon requiring reoperation. Another delayed coloanal anastomosis could be performed. Median followup was 43 months (range 6 to 113 months). Functional results were evaluated with a new scoring system including 13 items. Function was considered good in 59% and 70% at 1 and 2 years, respectively.

CONCLUSIONS

This new procedure is a safe and effective sphincter-preserving operation that avoids a diverting stoma for patients with rectal cancer of the lower third of the rectum. This technique is well adapted for patients receiving preoperative radiotherapy, with low local morbidity and good functional results. Further adaptation could be imagined for a coelioscopic approach.

Combined chemotherapy and radiotherapy followed by surgery in the treatment of patients with squamous cell carcinoma of the esophagus

BACKGROUND

Surgery remains the treatment of choice for patients with esophageal squamous cell carcinoma (SCC), but survival rates have not improved over the past decades. The objective of this study was to evaluate the effect of multimodal therapy on resectability, on the overall and on disease free survival (DFS) rates, and on the laryngeal resection rate.

METHODS

Fifty-five patients (49 men and 6 women) with a mean age of 58 +/- 8 years underwent combined modality treatment for esophageal SCC. The tumor location was in the upper one-third of the esophagus in 19 patients, the middle one-third in 22 patients, the lower one-third in 9 patients, and the upper and lower one-thirds in 5 patients. The intent of combined therapy was curative in 87.3% of patients and palliative in 12.7% of patients. Neoadjuvant treatment consisted of two courses of 5-fluorouracil and cisplatin on Days 1-5 and Days 21-25. Radiotherapy was commenced on Day 21 and consisted of 36 grays delivered in 12 fractions over 17 days. Surgery was performed on Day 60.

RESULTS

Full neoadjuvant treatment was possible in 67.3% of patients and was uneventful in 56. 4% of patients. The resection rate was 96.4% (complete macroscopic resection with histologic clear margins [R0], 83.6%; complete macroscopic resection with microscopic disease at the resection margin [R1], 1.8%; and macroscopic residual disease [R2], 10.9%). The operative mortality rate was 0%, whereas the hospital mortality was 7.3%. Twenty-three patients had a complete macroscopic response, 12 of whom (21.8%) had a complete histopathologic response. The tumor stages according to the American Joint Committee on Cancer staging system were pT0N0 in 12 patients, Stage 0 in 8 patients, Stage IIa in 6 patients, Stage IIb in 6 patients, Stage III in 8 patients, and Stage IV in 13 patients. Laryngeal preservation was achieved in 8 of 12 patients in whom total pharyngolaryngoesophagectomy initially was indicated because of tumor response and an R0 resection. The overall survival rates at 1 year, 3 years, and 5 years were 61%, 39%, and 33%, respectively, and the DFS rates were 49%, 32%, and 29%, respectively. The respective survival rates for responders were 82%, 58%, and 53%, and the DFS rates were 68%, 54%, and 48%.

CONCLUSIONS

Neoadjuvant treatment is tolerated well by most patients. Combination therapy increases the resectability rate and facilitates laryngeal preservation. Significant improvements in the actuarial survival rate and the DFS rate were observed in the group of patients who achieved partial and complete responses.

[Double irradiation for macroscopic radioresistance or recurrence of melanomas of the posterior uvea: clinical, ballistic, therapeutic and prognostic aspects. Series of 19 cases among 462 patients]

We describe two comparative series of patients treated with double-dose betaraysbrachytherapy (106 Ruthenium) between 1983 and 1994, and double-dose proton beam therapy between 1991 and 1996. The indications for double-dose irradiation with the same radio-element corresponded to "macroscopically abnormal" situations: immediate and prolonged radioresistance, recurrence or secondary radioresistance. Thirteen cases are called series 1 (Ruthenium) and 6 cases are called series 2 (protons). The series 1 allows a more reliable study as far as follow-up is higher (5.8 to 7.5 years) than in series 2 where the follow-up is shorter (13.6 to 29 months). Although double-dose irradiation was macroscopically efficient in 11 out of 13 cases in series 1, and in 3 out of 6 cases in series 2 (stabilization or decrease of tumour height measured before the second therapeutic session), 2 patients are deceased and 1 has a metastatic disease in the group "recurrence" of Ruthenium serie. Another one has also a metastatic disease in the group "recurrence" of protons series. Nevertheless double-dose radiotherapy allows a complementary decrease or stabilization of tumour height after a first session. It also decreases the indications for enucleation if there is no severe anatomic complications, when a tumour does not regress or recurs after a first session of radiations.

[Curative treatment of non-metastatic esophageal cancer: concomitant chemoradiotherapy and high-dose-rate endoluminal curietherapy boost]

OBJECTIVES

The aim of this study was to evaluate the feasibility, toxicity, and efficacy of a curative combination of chemo-radiotherapy with high-dose-rate brachytherapy (HDRB) in patients with non metastatic esophageal cancer.

PATIENTS AND METHODS

Fifty-two patients with esophageal carcinoma were treated with > 50 Gy external irradiation, concomitant chemotherapy (5FU-CDDP) followed by HDRB delivering 12.5 Gy (6-20) as a boost. Twelve patients were stage I, 20 stage IIa, 5 stage IIb, and 13 stage III, 1 Tis, 1 stage N unknown. Surgery was not indicated for medical reasons.

RESULTS

The response rate was 96%, with complete response rate 85%. The 1-, 3-, 5-year overall survival rates were 78%, 33%, and 22% respectively. A local failure occurred in 32%, and distant metastasis in 16%. Severe (grade 3, 4) acute toxicity occurred in 6 cases, severe late toxicity in 2 cases and there was 1 toxic death. Tumoral length > or = 5 cm and stage IIa, IIb and III versus stage 1 indicated poor prognosis.

CONCLUSION

This regimen is feasible and well tolerated. The 5-year overall survival is 22%, but the local failure rate is still very high. These results are encouraging and will be prospectively evaluated with currently ongoing randomized trial.

Curative external beam radiotherapy for prostate carcinoma: results in 231 patients treated in Lyon

BACKGROUND

Radical prostatectomy and external beam radiation therapy (EBRT) are the mainstays of treatment of prostate cancer with curative intent. The possible development of radiation proctitis and rectal bleeding are major concerns when using EBRT. Recently, conformal radiotherapy has been introduced in an attempt to improve the results of EBRT. This paper presents an overview of the Lyon experience using standard EBRT with doses of 68 Gy, and reports the preliminary results of a study of conformal radiotherapy with dose escalation.

METHODS

From 1981 to 1995, EBRT was used to treat 231 patients with localized adenocarcinomas of the prostate. The dose of EBRT was 68 Gy/34 fractions/7 weeks using a four-field box technique with 18-MeV photons. A feasibility study of conformal radiotherapy was commenced in 1996. To date, 145 patients have been treated with doses escalating from 68 to 80 Gy.

RESULTS

In the EBRT group of 231 patients, the 5-year overall survival was 80.3%. Anorectal function was scored as excellent in 90% of patients. Rectal bleeding was seen in 14.3% of patients and required local treatment in only seven. In the group treated with conformal radiotherapy, the preliminary results indicate good early tolerance.

CONCLUSION

The curative treatment of patients with prostate cancer using EBRT gives good long-term survival with low rectal toxicity. Conformal radiotherapy appears to be an interesting approach to improve local control and perhaps survival.

Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: the Lyon R90-01 randomized trial

PURPOSE

The optimal timing of surgery after preoperative radiotherapy in rectal cancer is unknown. The aim of this trial was to evaluate the role of the interval between preoperative radiotherapy and surgery.

PATIENTS AND METHODS

Patients with rectal carcinoma accessible to rectal digital examination, staged T2 to T3, NX, M0, were randomized before radiotherapy (39 Gy in 13 fractions) into two groups: in the short interval (SI) group, surgery had to be performed within 2 weeks after completion of radiation therapy, compared with 6 to 8 weeks in the long interval (LI) group. Between 1991 and 1995, 201 patients were enrolled onto the study.

RESULTS

A long interval between preoperative radiotherapy and surgery was associated with a significantly better clinical tumor response (53. 1% in the SI group v 71.7% in the LI group, P =.007) and pathologic downstaging (10.3% in the SI group v 26% in the LI group, P =.005). At a median follow-up of 33 months, there were no differences in morbidity, local relapse, and short-term survival between the two groups. Sphincter-preserving surgery was performed in 76% of cases in the LI group versus 68% in the SI group (P = 0.27).

CONCLUSION

A long interval between preoperative irradiation and surgery provides increased tumor downstaging with no detrimental effect on toxicity and early clinical results. When sphincter preservation is questionable, a long interval may increase the chance of a successful sphincter-saving surgery.

Treatment of squamous cell anal canal carcinoma with pulsed dose rate brachytherapy. Feasibility study of a French cooperative group

BACKGROUND AND PURPOSE

To evaluate the feasibility of pulsed dose rate (PDR) brochytherapy in squamous cell anal canal carcinoma (SCACC).

MATERIALS AND METHODS

In this study a series of 19 patients with SCACC were included between 1995 and 1997. All patients were treated with curative intent with external beam radiotherapy (EBRT) (44-50 Gy) and one or two cycles of concomitant fluorouracilcisplatinum. After a gap of 2-3 weeks PDR interstitial brachytherapy was performed with a rigid needles technique. The dose was between 10-25 Gy (PARIS system).

RESULTS

All patients are alive. No severe grade 3-4 toxicity was encountered. One local relapse one metastatis were seen in two distinct patients. There was no dysfunction of the after loading machine.

CONCLUSION

The feasibility of PDR brachytherapy appears good in SCACC. It is an attractive alternative to low dose rate brachytherapy.

[Analysis of genetic disorders of cancer of the rectum: differences in relation to cancer of the colon]

AIMS AND METHODS

We studied the mechanisms of colon and rectal carcinogenesis by analysing in a series of 83 rectal tumors the prevalence of the two tumor types characteristic of colon cancer, i.e., the LOH+ type, defined by p53 and APC mutations (studied by DGGE and protein truncation assay), and the RER+ type, which is characterized by the instability of some mononucleotide repeat microsatellites (Bat 25 and Bat 26). Additionally, we analyzed the occurrence of Ki-Ras mutations (direct sequencing).

RESULTS

Only one tumor turned out to be RER+. Moreover, in 59% of the tumor cases mutations were found in p53, essentially affecting codon 175. The APC and Ki-Ras genes were found to be mutated in 40 and 26% of the rectal tumors, respectively. In 18 tumors (21%) none of the genes studied were mutated.

CONCLUSIONS

The RER+ phenotype is rare among rectal tumors, which are essentially LOH+. In these LOH+ tumors the p53 gene is more frequently mutated than in colorectal tumors with the same phenotype. Mutations in the APC and Ki-Ras genes, on the other hand, are less frequent in rectal tumors. Tumors with the RER- and LOH- phenotype may develop as a result of a third carcinogenesis model which must be defined.

The role of radiotherapy in the conservative treatment of rectal carcinoma--the Lyon experience

The purpose of this study was to present the Lyon experience using radiotherapy alone or with surgery, with intent to cure rectal cancer and to avoid rectal amputation. Two groups of patients were treated between 1980 and 1996: Group I with radiotherapy alone with contact x-ray for T1 N0 (101 patients) or with a combination of external beam radiation therapy (EBRT), contact x-ray and 192 iridium implant in inoperable T2-3 N0-1 patients (43 patients); Group II with preoperative EBRT either as a pilot study (158 patients) or in a randomized trial (210 patients). With contact x-ray alone it was possible to control T1 N0 in 90% of cases, and with the combined approach 70% of the inoperable patients were controlled. In Group II, anterior resection was performed in 60% to 70% of the patients. Local recurrence was seen in 11% of cases. Surgery is the basic treatment used for rectal cancer but radiotherapy is playing an increasing role in the conservative treatment of this cancer.

Treatment of anal canal carcinoma with high dose radiation therapy and concomitant fluorouracil-cisplatinum. Long-term results in 95 patients

PURPOSE

To evaluate the long-term results of the treatment of anal canal carcinoma (ACC) with a combined concomitant radiochemotherapy (CCRT) treatment using fluorouracil (5 FU) and cisplatinum (CDDP) with a high dose of radiation therapy.

PATIENTS AND METHODS

Between 1982 and 1993 a series of 95 patients were treated. Staging showed a majority of advanced squamous ACC, i.e. 6 T1, 47 T2, 28 T3, 14 T4, 53 NO, 32 N1, 6 N2 and 4 N3. Irradiation was done with high dose external beam radiation therapy (EBRT) followed by a boost with 192 Iridium implant. During EBRT all patients received one course of 5 FU continuous infusion (1 g/m2/day, days 1-4) and CDDP (25 mg/m2/day, bolus days 1-4).

RESULTS

The median follow-up time was 64 months. At 5 and 8 years the overall survival was 84 and 77%, the cancer specific survival was 90 and 86% and the colostomy-free survival was 71 and 67%, respectively. The stage and the response of the tumor after EBRT were of prognostic significance. Patients with pararectal lymph nodes had an overall 5-year survival of 76% (versus 88% for non-N1). Among 78 patients who preserved their anus, the anal sphincter function was excellent or good in 72 (92%).

CONCLUSION

According to these results and recent randomized trials, CCRT appears as the standard treatment of ACC. Radical surgery should be reserved for local recurrence or persisting disease after irradiation. High dose irradiation in a small volume with concomitant 5 FU-CDDP appears to give a high rate of long-term local control and survival. Careful evaluation of pararectal nodes is essential for a good staging of the disease.

Sphincter preservation in rectal cancer. Endocavitary radiation therapy

Endocavitary radiation therapy (Endo RT) is performed mainly with a contact x-ray tube. Interstitial brachytherapy is a supplementary method to boost the tumor bed. Only strictly selected patients can be treated for cure by Endo RT. More than 1,000 patients have been treated in Europe and North America since 1950. In T1 N0 adenocarcinoma, the primary local control rate is close to 90%. The overall 5-year survival is between 60% and 90% depending on patient selection. Careful follow-up is necessary because the majority of local failures can be salvaged, usually by radical surgery. The main advantages of Endo RT are a fully ambulatory and simple treatment that can be applied even in frail or elderly inoperable patients, a low risk of complications, and an inexpensive treatment. Results show it is possible to perform curative treatment in patients with more advanced rectal carcinoma. With the combination of external-beam radiation therapy and Endo RT in stage T2-3 N0-1 tumors, the primary local control rate is around 70%, and the incidence of severe radiation toxicity is less than 5%. Overall 5-year survival is between 50% and 70%. Endo RT can also be used as an adjuvant treatment after local excision, in the treatment of villous adenomas, and for palliation of advanced inoperable tumors.

Intraoperative radiation therapy combined with limited lymph node resection in gastric cancer: an alternative to extended dissection?

PURPOSE

To describe the results of a series of 63 Western patients presenting with gastric adenocarcinoma and treated with surgery and intraoperative radiation therapy (IORT) over a 8-year period and to discuss the role of IORT when combined with limited lymph node dissection.

METHODS AND MATERIALS

From 1986 to 1993, 63 patients with gastric adenocarcinoma have been operated in the department of radiation oncology of the Hospices Civils de Lyon. The stage was: I in 17, II in 11, IIIA in 9, IIIB in 20, and IV in 6. The lymph node dissection was considered to be limited in 56 patients and extended in 7. The IORT dose ranged from 12 to 23 Gy (median: 15). Thirty patients also underwent a postoperative external beam irradiation with a standard dose of 44-46 Gy.

RESULTS

The postoperative mortality rate was 4.8%. The 5-year overall survival in the entire series was 47% and was 82, 55, 78, 20, and 0% in Stages I, II, IIIA, IIIB, and IV, respectively. Loco-regional relapse occurred in 15 of 63 patients and metastases in 15 of 63.

CONCLUSION

In Western patients treated by gastrectomy for adenocarcinoma of the stomach, IORT combined with limited lymph node dissection may provide overall survival similar to that observed after gastrectomy with extended lymph node dissection but with less postoperative mortality.

Intraoperative radiotherapy in resected pancreatic cancer: feasibility and results

BACKGROUND AND PURPOSE

To evaluate the impact of intraoperative radiotherapy (IORT) combined with postoperative external beam irradiation in patients with pancreatic cancer treated with curative surgical resection.

MATERIALS AND METHODS

From January 1986 to April 1995 25 patients (11 male and 14 female, median age 61 years) underwent a curative resection with IORT for pancreatic adenocarcinoma. The tumour was located in the head of the pancreatic gland in 22 patients, in the body in two patients and in the tail in one patient. The pathological stage was pT1 in nine patients, pT2 in nine patients, pT3 in seven patients, pN0 in 14 patients and pN1 in 11 patients. All the patients were pM0. A pancreaticoduodenectomy was performed in 22 patients, a distal pancreatectomy was performed in two patients and a total pancreatectomy was performed in one patient. The resection was considered to be complete in 20 patients. One patient had microscopic residual disease and gross residual disease was present in four patients. IORT using electrons with a median energy of 12 MeV was performed in all the patients with doses ranging from 12 to 25 Gy. Postoperative EBRT was delivered to 20 patients (median dose 44 Gy). Concurrent chemotherapy with 5-fluorouracil was given to seven patients.

RESULTS

The overall survival was 56% at 1 year, 20% at 2 years and 10% at 5 years. Nine local failures were observed. Twelve patients developed metastases without local recurrence. Twenty patients died from tumour progression and two patients died from early postoperative complications. Three patients are still alive; two patients in complete response at 17 and 94 months and one patient with hepatic metastases at 13 months.

CONCLUSION

IORT after complete resection combined with postoperative external beam irradiation is feasible and well tolerated in patients with pancreatic adenocarcinoma.

[Peroperative radiotherapy in the conservative treatment of infiltrating bladder cancers]

OBJECTIVE

Descriptive analysis of an intraoperative radiotherapy protocol (IOR) in the context of conservative management of invasive bladder cancer.

METHOD

From November 1988 to September 1994, 24 patients with invasive bladder carcinoma (20 T2, 3 T3) were included in this protocol consisting of: transurethral resection (TUR), neoadjuvant chemotherapy (M.V.C.) in 14 patients, external irradiation (x 18 MV: 48 Gy/24 F/5 weeks) with concomitant chemotherapy (cisplatin 30 mg/day-3 days-2 cycles during irradiation)-follow-up cystoscopy then surgery with IOR (E 9 MeV: 15 Gy).

RESULTS

The global 3-year survival was 69%. An invasive intravesical relapse developed in 3 patients (1 salvaged by cystectomy) and a superficial relapse occurred in 1 patient. One patient developed pelvic lymph node progression and 7 developed distant metastases. The early and late toxicity was acceptable with 3 cases of ureteric necrosis or stenoses resolving after medical treatment.

CONCLUSION

This series shows encouraging preliminary results. IOR appears to be a technique well adapted to lesions of the fixed portion of the bladder.

Stereotactic radiosurgery for arteriovenous malformations of the brain using a standard linear accelerator: the Lyon experience

Radiosurgery (RS) was initiated in Lyon in October 1989. The technique was adapted from that described by Lutz and Saunders in Boston (BRW stereotactic frame). Irradiation is delivered with 18-MV photons produced by a LINAC. From December 1989 to December 1992, 41 patients with arteriovenous malformations were treated by RS; the median age was 33 years. The largest lesion diameter was 11.2-38.5 mm. Fifteen to 20 Gy were delivered on the 70% isodose line. Angiography was performed at 2 years post-treatment in 32 patients demonstrating an overall complete thrombosis rate of 81.3%. This incidence was significantly correlated with the Spetzler and Martin grade before RS (P = 0.0055). Two patients (4.9%) experienced haemorrhage after radiosurgical treatment and one died from an intracerebral-intraventricular haemorrhage. Four patients (9.7%) experienced permanent radiation-induced neurological complications.

Combined curative radiation therapy alone in (T1) T2-3 rectal adenocarcinoma: a pilot study of 29 patients

AIM

Analysis of a pilot study including 29 consecutive patients with high surgical risk or refusal of colostomy treated with radiation therapy alone with curative intent.

PATIENTS

Between 1986 and 1992, 29 patients were treated for infiltrating adenocarcinoma of the rectum. Median age was 72 years. Transrectal ultrasound staging was used in 24 patients (T1, 2; T2, 14; T3, 13; N0, 23; N1, 6). In 20 patients the lower border of the tumor was at 5 cm or less from the anal verge and in 19 patients the diameter exceeded 3 cm. CEA was elevated in seven cases.

TREATMENT

Contact X-ray (50 kV) was given first (70 Gy/3 fractions). External beam radiation therapy used a three-field technique in the prone position. Accelerated schedule (39 Gy/13 fractions/17 days) with a concomitant boost "field within the field' (4 Gy/4 fractions). Six weeks later an iridium-192 implant was performed in 21 (20 Gy/22 h).

RESULTS

Median follow-up time was 46 months. Overall and specific survival at 5 years was 68% (SE = 0.09) and 76% (SE = 0.08). Local control was obtained in 21/29 patients (72%). There was one grade 2 rectal bleeding and five grade 2 rectal necroses. The overall tolerance was good in these frail patients.

DISCUSSION

For T2. T3 or T1 > 3 cm diameter rectal adenocarcinoma, where contact X-ray alone is not recommended, a combined treatment with radiation therapy alone is able to give good local control with acceptable toxicity. This treatment should be restricted to inoperable patients.

Complications after multidisciplinary treatment of cerebral arteriovenous malformations

PATIENTS AND TECHNIQUES

A series of 67 patients treated for cerebral AVMs with a multidisciplinary approach is reported, with special attention for the complications due to treatment. The malformations were classified after the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: resection alone (25% of cases), embolization plus resection (24%), embolization alone (21%), and radiosurgery (30%), either alone or after embolization or surgery. The following eradication rates were obtained: overall 80%, after resection (with or without embolization) 91%, after embolization alone 13%, after radiosurgery 87%.

CLINICAL OUTCOME

The outcome was evaluated in terms of deterioration due to treatment. A deterioration after treatment occurred in 19 patients (28%), and was a minor deterioration (19%), a neurological deficit (4%), or death (4%). As far as the mode of treatment is concerned, surgical resection was responsible for deterioration (minor) in 17% of all cases operated upon. Radiosurgery was followed by a minor deterioration in 10% of irradiated cases. Embolization gave a complication in 25% of all embolized cases (minor or neurological deficit, or death). The mechanism of the complications was: resection or manipulation of an eloquent area during surgery, radionecrosis after radiosurgery, ischaemia and haemorrhage (50% each) following embolization. In most cases of haemorrhage due to embolization, occlusion of the main venous drainage could be demonstrated.

DISCUSSION

The haemodynamic disturbances to AVMs and to their treatment are reviewed in the literature. The main haemodynamic mechanisms admitted at the beginning of a complication after treatment of cerebral AVMs are the normal perfusion pressure breakthrough syndrome, the disturbances of the venous drainage (venous overload or occlusive hyperaemia), and the retrograde thrombosis of the feeding arteries.

CONCLUSIONS

According the authors' experience, the emphasis of treatment for cerebral AVMs has now shifted from surgical resection to endovascular embolization. One of the explanations is that endovascular techniques are now employed in the most difficult cases (high grade AVMs). As severe complications of endovascular embolization may also occur for low-grade malformations, the question arises whether surgery or radiosurgery should not be used first for this low-grade group even if embolization is feasible.

Multidisciplinary treatment of cerebral arteriovenous malformations

A series of 67 patients treated for cerebral AVM with a multidisciplinary approach is reported. The malformations were classified after the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: surgical resection alone (25% of cases), embolization plus resection (25% of cases), embolization alone (21%) and radiosurgery (30%) either alone (12%), or after incomplete embolization (15%) or after incomplete resection (3%). The clinical outcome was evaluated in terms of deterioration due to treatment. The treatment was responsible for a deterioration in 28% of all patients, either minor deterioration (19%) neurological deficit (4%), or death (4%). All complications of surgical resection (17% of all operated cases) and of radiosurgery (10% of irradiated cases) remained minor. None was haemodynamic-related. After endovascular embolization, a deterioration occurred in 25% of all embolized cases (minor 13%, neurological deficit 5% and death 8%). These complications occurring after embolization were haemodynamic related: ischaemia and haemorrhage (50% for each mechanism). Haemorrhage occurred either during or some days after the embolization procedure. The angiographic eradication rate was: 80% overall, 91% after resection (with or without previous embolization), 87% after radiosurgery (alone or after other techniques), and 10% after embolization alone. The discussion reviews in the literature the general evolution of the management of cerebral AVMs, with successive application of first surgical resection, the embolization and lastly radiosurgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention of radiation related complications in the treatment of rectal adenocarcinoma. The importance of the dose volume relationship

AIM

To illustrate and stress the role of the dose volume relationship in the risk of radiation induced rectal complications.

METHODS

With different techniques of irradiation like contact x ray therapy, Iridium implant, external beam irradiation, intra operative electrontherapy, it is possible to irradiate different volumes from few centicubes to liters.

RESULTS

The data from the literature clearly demonstrate that high doses can be given safely in small volumes, but that doses of 50 Gy or more in large volumes are dangerous. The irradiation of the whole pelvis through two antero posterior (AP - PA) fields ecompassing more than 4 liters should not be recommended. Other classical risk factors must be taken into account when planning the treatment. Previous surgery, obesity, diabetus, collagen disease, combined chemotherapy, all these factors can lead to a modification of the irradiation technique.

CONCLUSIONS

A perfect technique of irradiation is mandatory to achieve the best therapeutic ratio when treating rectal cancer. To avoid severe complications the dose must be closely adapted to the irradiated volume.

Stereotactic radiosurgery: the Lyon experience

From 10/1989 to 12/1992, 135 patients were treated, in Lyon, by Stereotactic Radiosurgery (RS) +/- External beam Radiotherapy (EBRT). Indications were AVMs or tumours that could not be cured by embolisation or/and surgery and are not larger than 30 to 35 mm. Lesions received 15 to 20 Gy (70% isodose) in one course. Among the 42 AVMs, only one rebled 6 months after RS and 9/15 had clinical improvement. Thirty-one had a radiological follow-up of 4 to 29 months after RS. Ten were totally obliterated, seven regressed more than 80% and six had a reduction of 50 to 80% of their AVM. Three grade 3 radio necrosis occurred for a cerebral trunk AVM and two large lesions. Three of the 15 treated meningiomas progressed after RS, 2 of them were controlled by conventional surgery. Four out of nine presenting symptoms had clinical improvement and, with a radiological follow-up of 4 to 24 months, 5 were stabilised and 6 regressed. Two grade three complications occurred for large lesions. The biological and radiological results of RS were good for the 42 treated pituitary adenomas but the high visual complication rate (12/42 with 8 grade 3) was too important and we stopped RS for these tumours except for small (less than 2 cm) adenoma at some distance from the optic chiasma. The visual complications were related to the tumour volume, the distance between the adenoma and the visual tract and pre-existent visual alterations.(ABSTRACT TRUNCATED AT 250 WORDS)

Curative endocavitary irradiation of small rectal cancers and preoperative radiotherapy in T2 T3 (T4) rectal cancer. A brief overview of the Lyon experience

The aim of this study was the analysis of 414 patients treated by endocavitary irradiation for small T1 (T2) infiltrating adenocarcinomas between 1951-93 and of 337 patients treated by preoperative radiotherapy for T2 T3 (T4) rectal cancer, between 1978-92. Endocavitary irradiation was delivered with Papillon's technique using the PHILLIPS RT-50 machine. Preoperative external beam radiotherapy was given to the posterior pelvis only with an accelerated schedule of 39 Gy in 13 fractions over 18 days. Endocavitary irradiation with the use of intra-rectal ultrasound for patient selection resulted in a local control rate of 91% with no complication even in the medically inoperable patients. Preoperative external beam radiotherapy followed by radical resection resulted in a 90% pelvic control rate. Sphincter-sparing surgery was possible in 60% of patients with low or middle rectal lesions.

Primary carcinoma of the gall-bladder: potential for external radiation therapy

Nineteen patients (14 women, 5 men) received external radiation therapy (ERT) between 1980 and 1988 for gall-bladder carcinoma. Eleven patients had complete resection (cholecystectomy in eight cases), six incomplete gross resection and two only percutaneous transhepatic biliary drainage (PTBD). The modalities of ERT were variable and doses ranged from 30 Gy/10 fractions to 50 Gy/25 fractions. Among 11 patients with complete resection (9/11 with T1 or T2 stages), overall survival was 55% at 48 months and 36% at 60 months, median survival was 48 months and at the time of this report 3/11 patients were alive with no evidence of disease, 54, 65, 76 months after surgery, and eight dead of cancer 8-114 months. Local control was achieved in 66 patients with T1 or T2 stages. All eight patients who had palliative surgery or PTBD died of cancer after 4-20 months with median survival of 6 months. Three complications were noted: one gastric ulcer in the course of ERT (surgical treatment), one duodenal ulcer which occurred 6 months after completion of ERT (medical treatment) and one regressive radiation hepatitis. From this experience it appears that ERT in gall-bladder carcinoma is well tolerated, can obtain local control and prolonged survival after complete resection and good palliation in non-resectable tumors.

The use of radiotherapy for patients with low rectal cancer: an overview of the Lyon experience

In France, the late Jean Papillon was responsible for much of the pioneering work in the radiotherapy treatment of patients with rectal cancer. This review is written in tribute to his contribution to, and vast experience in, the conservative management of this common tumour. It describes his protocols with minor modifications currently used at the Centre Hospitalier Lyon-Sud, France. In Lyon, pre-operative adjuvant irradiation is the preferred treatment for patients with T2 and T3 rectal cancer. Initial results suggest that this combined approach significantly improves the likelihood of successful sphincter preservation for patients with carcinoma of the lower third of the rectum. To date, the technique has given good local control with minimal postoperative morbidity and low mortality.

Radiation therapy in the conservative treatment of carcinoma of the anal canal

PURPOSE

Radiotherapy is the standard treatment of anal canal carcinoma. We retrospectively analyzed our experience with 108 patients. Special attention was given in evaluating 51 patients who received concomitant chemotherapy with 5-FU-CDDP.

METHODS AND MATERIALS

From January 1980 to December 1989, 108 patients with anal canal carcinoma were treated with exclusive radiotherapy at the Centre Hospitalier Lyon Sud. There were 11 men and 97 women, mean age was 65 years (30-86). Histologic types were 94 epidermoid carcinomas, 13 basaloid carcinomas, and one adenocarcinoma. The TNM classification (UICC 87) was: 16 T1 (14.8%), 53 T2 (49%), 33 T3 (39.5%), six T4 (5.5%), 77 N0 (71.3%), 20 N1 (18.5%), nine N2 (8.3%) and two N3 (1.8%). Papillon's radiotherapy technique with a Cobalt direct perineal field was used in 82 patients. Ninety-six patients were treated with an interstitial 192Ir implant with a mean delay of 55 days after the end of the radiotherapy. In 59 patients at least one course of either 5-FU-mitomycin (8) or 5-FU-CDDP was added with at least one course concomitantly to the radiotherapy in 53 patients.

RESULTS

A complete response in 104/108 patients (96%) was obtained 2 months after the brachytherapy. A locoregional relapse (local and/or pelvic failure) was seen in 18 patients (16.6%) and inguinal node relapse in nine (8.3%). Eight patients with locoregional recurrence and five with inguinal relapse were salvaged. A systemic failure occurred in six (5.5%) patients. Twenty-nine patients died, 16 of progressive disease. One patient died of treatment related toxicity. The overall 5-year survival was 64% +/- 6 and specific survival 72% +/- 8. None of the patient parameters was found to be statistically significant but there was a trend toward longer 5-year survival in T1-T2 patients and in those with well or moderately differentiated tumors. Noteworthy are the same survival rates for N0 and N1-N3 patients (65 vs. 62%). The objective response and the locoregional failure rates were similar in the patients treated with or without chemotherapy. The difference did not reach statistical significance though it was important for the following parameters: overall survival rates for T1-T2 with and without chemotherapy (94 vs. 61%) and for N1-3 patients (73% vs. 27%). The main prognostic factors in this series were differentiation (5-year overall survival with chemotherapy 95% vs. 27% without chemotherapy p = 0.02) and the response at 3 months after treatment initiation, before brachytherapy implant (5-year overall survival for complete responders and "very good responders" 71% vs. 34% in partial responders p = 0.002). The complications rate was acceptable (Grade III 9%, Grade II 14%). Anal preservation was possible in 85% of the patients (92/108). Nine abdominoperineal resection were performed for recurrence and seven for severe necrosis. The T3-T4 group abdomino perineal resection was 23% while it was 9.2% of the T1-T2 group.

CONCLUSION

We confirm that exclusive radiotherapy is the treatment of choice for epidermoid carcinomas of the anal canal. The role of chemotherapy is still unclear.

Radiation therapy in proliferative vitreoretinopathy. A prospective randomized study

In a prospective study of the effect of postoperative radiation therapy for the prevention of reproliferation of membranes and recurrent proliferative vitreoretinopathy (PVR) two similar groups of patients with retinal detachment and PVR grade D1 to D3 in one eye were compared. Half the eyes (30) received a total dose of 3000 cGy after surgery; the other half remained untreated. After a follow-up of 6 months and 14 months or more (maximum 36 months) the anatomical and functional results of each group were compared. After 6 months in the unirradiated group 57% (17/30) remained attached and 43% (13/30) had detached again. In the irradiated group 63% (19/30) were attached and 37% (11/30) had detached. However, there was no statistically significant difference between the two groups (P = 0.479, Fisher's Exact Test). After 14 months the number of cured and uncured eyes remained the same in the unirradiated group, while in four of the eyes in the irradiated group a later onset of reproliferation and detachment occurred (after 7, 8, 12 and 14 months, respectively). A final cure rate of 57% (17/30) was achieved in the unirradiated group and a 50% (15/30) cure rate in the irradiated group. Thus the failure rate was 43% (13/30) in the unirradiated group and 50% (15/30) in the irradiated group (P = 0.473, Fisher's Exact Test). No side effects from the radiation were observed in any case and no radiation retinopathy occurred during an observation period of up to 3 years.(ABSTRACT TRUNCATED AT 250 WORDS)

An original technique of brachytherapy for T1 T2 carcinomas of the mobile tongue

Twenty-four patients with T1 or T2 (17 T1 N0, 7 T2 N0 not exceeding 3 cm) epidermoid carcinomas from the middle third of the mobile tongue benefit from brachytherapy with "cavaliers-legos" consisting of guide-gutters that are inserted in a rigid support (legos) and covered with a lead plate. Several advantages can be advocated with this technique: easy implantation even with local anaesthetic, no risk of bleeding, good parallelism between Iridium wires, protection of the mandible with the lead plate. Local control was achieved in 22/24 patients (92%). Four patients (16%) developed soft tissue necrosis but only one required surgical intervention and no mandibular necrosis was seen.