E. Bussieres

Recurrences of rectal cancers: Results of a multimodal approach with intraoperative radiation therapy

PURPOSE Prognosis of recurrent rectal cancer remains poor, mainly because of the difficulties of achieving a satisfactory local control. Intraoperative radiation therapy (IORT) allows for the delivery of a complementary single dose to the tumor residues or to the tumor bed and could be useful jn a multimodal treatment. In an attempt to evaluate this interest, a retrospective analysis of patients treated with IORT in six French hospitals has been performed. METHODS AND MATERIALS Data have been collected in 73 patients (41 men), with a mean age of 62 years, treated with IORT. Initial rectal tumors were large (mean diameter: 45 mm), partially or totally fixed to the contiguous structures in 39%, and with nodal involvement in 50% of the cases. Initial surgery had been a sphincter-sparing surgery in 67%; external radiation therapy had been delivered in 52%, and a chemotherapy had been given in 10% of the patients. Recurrences were isolated (without metastases) in 86%, and were posterior or posterolateral in 55% of the cases. Surgery allowed for a complete macroscopical resection in 57%, a partial resection with gross residual disease in 29%, and no resection in 14% of the recurrences. Intraoperative radiation therapy was delivered in a dose of 10 to 25 Gy (mean 18.5) through localizators of a mean diameter of 75 mm (60 to 110). External radiation therapy, either preoperative or postoperatively was given to 30 patients without prior radiation therapy. Ten patients received additional chemotherapy with 5-fluorouracil. RESULTS Four postoperative deaths occurred. Postoperative morbidity occurred in 16 patients and some complications were probably related to the IORT procedure. Four long-term complications were observed. Overall actuarial survival occurred in 72.4% of the patients at 1 year, in 44.6% at 2 years, and in 30.6% at 3 years. Twenty-one local failures have been observed. Actuarial local control occurred in 71.3% of the patients at 1 year, 47.7% at 2 years, and 31.3% at 3 years. CONCLUSION Intraoperative radiation therapy is a complementary treatment for recurrences of rectal cancer. It provides encouraging results, particularly in some selected situations, when patients have not previously been treated with external radiation therapy. Further studies of multimodal treatments are necessary.

Intraoperative radiation therapy in recurrent carcinoma of the uterine cervix: Report of the French intraoperative group on 70 patients

PURPOSE To evaluate the feasibility and oncologic results of intraoperative radiation therapy (IORT) for recurrent uterine cervical carcinoma in a cohort of patients treated in seven French institutions. METHODS AND MATERIALS From 1985 to 1993, 70 patients with pelvic recurrences underwent IORT with/ without external radiation therapy (ERT) and chemotherapy (CT). Treatment modalities for recurrence were IORT alone (40 out of 70), IORT + ERT (30 out of 70), additional chemotherapy (20 out of 70). Gross complete resection (CR) was performed in 30 out of 70 cases, partial resection (PR) in 37 out of 70, and unspecified surgery in 3 out of 70. Sixty-five patients had electron beam IORT and 5, 100 KV photon IORT. Mean IORT cone size, electron beam energy, and dose (calculated at the 90% isodose line) were, respectively, 75 mm (40 to 90), 12 MeV (6 to 20), and 18 Gy (10 to 25) after CR and 80 mm (45 to 100), 15 MeV (7 to 24), and 19 Gy (10 to 30) after PR. RESULTS Mean follow-up after IORT was 15 months (2 to 69). One, 2- and 3-year overall survival rates were 47, 17, and 8%, respectively; median survival was 11 months and local control, 21%. Median survival and local control rates increased after CR (13 months, 27%) vs. PR (10 months, 17%) and when initial treatment consisted of surgery (S) alone (15 months, 25%) vs. radiation therapy (RT +/- S) (10 months, 16%). However, these differences were not statistically significant. No death-related toxicity was observed. Grade 2 or 3 toxicity was observed in 19 out of 70 patients (27%), including 9 not directly IORT-related complications (13%) (three digestive tract fistulas, one rectal stricture, three urinary fistulas, two infections) and 10 directly IORT-related complications (14%) (five neuropathies, four ureteral obstructions, and one rectal stricture). CONCLUSION This retrospective study demonstrates the feasibility of IORT. The usefulness of IORT still needs to be evaluated in primary treatment of advanced stages of cervical carcinoma.

Retroperitoneal soft tissue sarcomas: A pilot study of intraoperative radiation therapy

This pilot study was conducted to evaluate the feasibility and tolerance of a multimodal therapy of retroperitoneal soft tissue sarcoma (STS), including intraoperative radiation therapy (IORT). Nineteen patients (14 primarily treated patients and 5 treated for a recurrent tumor) were included. Surgery included a complete resection (14), a partial resection (2), and no resection (2). The median IORT dose was 17 Gy. Thirteen patients also received an external radiation therapy (ERT). Nine patients received chemotherapy. There was no postoperative mortality. Immediate postoperative complications occurred in four patients (21%). Delayed complications occurred in six patients, including one lethal iliac artery disruption. With a median follow‐up of 17 months, the 2‐year disease‐free survival rate was 60%, and the 2‐year actuarial local control rate was 76%. A multimodality approach of treatment, including IORT and ERT and eventually chemotherapy, appears feasible in patients with retroperitoneal STS. However, the treatment‐related morbidity appeared relatively high in this study.

Cost comparison of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. A national study based on a prospective multi-institutional series of 985 patients ‘on behalf of the Group of Surgeons from the French Unicancer Federation’

BACKGROUND Our objective was to assess the global cost of the sentinel lymph node detection [axillary sentinel lymph node detection (ASLND)] compared with standard axillary lymphadenectomy [axillary lymph node dissection (ALND)] for early breast cancer patients. PATIENTS AND METHODS We conducted a prospective, multi-institutional, observational, cost comparative analysis. Cost calculations were realized with the micro-costing method from the diagnosis until 1 month after the last surgery. RESULTS Eight hundred and thirty nine patients were included in the ASLND group and 146 in the ALND group. The cost generated for a patient with an ASLND, with one preoperative scintigraphy, a combined method for sentinel node detection, an intraoperative pathological analysis without lymphadenectomy, was lower than the cost generated for a patient with lymphadenectomy [€ 2947 (σ = 580) versus € 3331 (σ = 902); P = 0.0001]. CONCLUSION ASLND, involving expensive techniques, was finally less expensive than ALND. The length of hospital stay was the cost driver of these procedures. The current observational study points the heterogeneous practices for this validated and largely diffused technique. Several technical choices have an impact on the cost of ASLND, as intraoperative analysis allowing to reduce rehospitalization rate for secondary lymphadenectomy or preoperative scintigraphy, suggesting possible savings on hospital resources.BACKGROUND Our objective was to assess the global cost of the sentinel lymph node detection [axillary sentinel lymph node detection (ASLND)] compared with standard axillary lymphadenectomy [axillary lymph node dissection (ALND)] for early breast cancer patients. PATIENTS AND METHODS We conducted a prospective, multi-institutional, observational, cost comparative analysis. Cost calculations were realized with the micro-costing method from the diagnosis until 1 month after the last surgery. RESULTS Eight hundred and thirty nine patients were included in the ASLND group and 146 in the ALND group. The cost generated for a patient with an ASLND, with one preoperative scintigraphy, a combined method for sentinel node detection, an intraoperative pathological analysis without lymphadenectomy, was lower than the cost generated for a patient with lymphadenectomy [€2947 (σ = 580) versus €3331 (σ = 902); P = 0.0001]. CONCLUSION ASLND, involving expensive techniques, was finally less expensive than ALND. The length of hospital stay was the cost driver of these procedures. The current observational study points the heterogeneous practices for this validated and largely diffused technique. Several technical choices have an impact on the cost of ASLND, as intraoperative analysis allowing to reduce rehospitalization rate for secondary lymphadenectomy or preoperative scintigraphy, suggesting possible savings on hospital resources.

Breast cancer and in vitro fertilization. About 32 cases.

Because of the increased risk of breast cancer for infertile nulliparous women, the suspected promoter role of estradiol in mammary carcinogenesis and the high frequency of ovulation inducer treatments, it was interesting to focus on the risk of breast cancer after such a treatment. We reviewed 32 cases during a retrospective survey in Assisted Reproductive Techniques (ART) centers in France. Because of the small sample size and the few cases published so far, no statistical study could be made. However, many observations may have gone unnoticed or were not published. Two hypotheses can be proposed: (1) the facilitating role of stimulation on potential infra-clinical or un-diagnosed cancers; (2) the initiation of new cancers. Consequently, we propose to establish a register for the follow-up of treated women to monitor the advent of new cancers and to increase the follow-up of patients with other associated risk factors.

Sarcomes primitifs du sein: À propos d’une série rétrospective de 42 cas traités à l’Institut Bergonié sur une période de 32 ans

OBJECTIVE To evaluate the experience of a single cancer center with unusual tumors. To analyze Primary breast sarcomas (PBS). To investigate treatment and prognostic factors influencing overall survival (OS) and disease-free survival (DFS). PATIENTS AND METHODS Retrospective study of a series of 42 patients. We reviewed the clinical records and pathology slides of 42 women with PBS treated in our institution between 1970 and 2002. Log-rank tests were used to determine OS and DFS. RESULTS The median age at diagnosis was 56.9 years (24-81 years). Surgery was part of the therapeutic strategy in all the patients. Patients with angiosarcoma and those with malignant cystosarcoma constituted distinct populations. The 10-year OS and DFS rates were 53% and 55% for angiosarcoma patients and 89% and 100% for cystosarcoma patients (p=0.009 and 0.01 respectively). CONCLUSION Careful preoperative multidisciplinary assessment is required before making the decision to treat. Mastectomy is generally indicated. Axillary lymph node dissection is not indicated.Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 33 - N° 7 - p. 589-599

La radiothérapie du sein et de la paroi thoracique : les volumes à traiter

The radiotherapy of the breast or the chest wall is a complex technique. The definition of the gross tumour volume and the clinical target volume depends on clinical, anatomical and histological criteria. The volumes are located by physical examination, mammography, echography and tomodensitometry. The implantation of surgical clips in the lumpectomy cavity is useful for the boost field. The planning target volume takes into consideration movements of tissues during respiration and variations in beam geometry characteristics. The organs at risk (heart, lung) must be considered systematically. Technical contrivances are necessary to modify and homogenize dose distribution. Conformational irradiation allows an individually design treatment planning. Intensity-modulated radiotherapy technique is a future advantageous technique still under evaluation.

Les prélèvements mammaires en stéréotaxie : macrobiopsies avec aspiration et biopsies chirurgicales stéréotaxiques

Resume Des techniques recentes de prelevements mammaires assistes par la stereotaxie sont utiles pour le diagnostic des images mammaires infracliniques depistees et permettent d’eviter un grand nombre de biopsies chirurgicales classiques. Les modalites techniques des macrobiopsies avec aspiration et des biopsies chirurgicales stereotaxiques sont decrites, ainsi que leurs avantages, leur fiabilite pour etablir le diagnostic histologique ou la confirmation diagnostique pretherapeutique, et les complications, limites, et inconvenients de ces methodes. Leur place dans la prise en charge des anomalies mammaires infracliniques est discutee en fonction de la classification Breast Imaging Reporting and Data System (BI-RADS) de l’ American College of Radiology .Stereotactically-guided procedures for diagnosis of breast lesions can avoid a lot of surgical biopsies. Stereotactic guidance is used for vacuum-assisted core biopsies and for stereotactic breast biopsies. Technical details of the procedures are described, and the benefits and the limits of these methods are discussed. Indications for breast sampling are proposed according to the Breast Imaging Reporting and Data System (BI-RADS) assessment categories.

Neoadjuvant endocrine treatment in breast cancer: analysis of daily practice in large cancer center to facilitate decision making

BACKGROUND To examine outcomes of neoadjuvant endocrine therapy in daily practice to inform decision making. METHODS We retrospectively selected 204 patients who received neoadjuvant endocrine therapy with T2 (≥30 mm) or T3 tumors, examining subsequent breast-sparing surgery and long-term outcomes. RESULTS Neoadjuvant endocrine therapy was administered for 7.3 months (median) and breast-sparing surgery was achievable in 53% of patients. Smaller initial tumor size and modified version of the Scarff-Bloom and Richardson grades 1 to 2 were associated with breast-sparing surgery. Disease progression during treatment was 6.9%; actuarial risk of local relapse was 3% at 5 years and 15% at 10 years. Five- and 10-year metastasis relapse-free survival was 78% and 63%, respectively. Grade 3, negative progesterone receptors, and absence or slow response to neoadjuvant therapy were associated prognostic factors. CONCLUSION These daily practice data provide important information about feasibility, efficacy, and long-term results of neoadjuvant endocrine therapy and can be used to inform patients for decision making between mastectomy and endocrine induction therapy.

High dose folinic acid and 5‐fluorouracil bolus and continuous infusion for patients with advanced colorectal cancer

Background. Palliative chemotherapy remains a challenge for oncologists. The combination of high dose folinic acid (HDFA) with 5‐fluorouracil (5‐FU) improves response rates, as do continuous infusions of 5‐FU. These protocols have limiting toxicities such as diarrhea, stomatitis, and leukopenia. Another schedule of 5‐FU and folinic acid has proven effective and is very well tolerated. The results of a similar regimen are reported.