G. Ganem

Salvage irradiation of oropharyngeal cancers using iridium 192 wire implants: 5-Year results of 70 cases

Between May 1971 and November 1980, 70 patients with recurrent or new oropharyngeal cancers arising in previously irradiated tissues were treated using iridium 192 afterloading techniques. The actuarial local control was 72% at 2 years and 69% at 5 years. Although local control of the tumor was achieved in the majority of these patients, only 10 patients remained alive at 5 years (14%). Patients with lesions of the faucial arch and posterior pharyngeal wall had the best results; local control was achieved in 100% of these patients. Patients with lesions of the base of tongue and of the glosso-tonsillar sulcus had poorer results; local control was achieved in 61%. Because these results compare favorably with the results of previously published series, we recommend re-irradiation with brachytherapy for recurrent or new malignancies arising in a previously irradiated oropharynx. When the lesion is located in the faucial arch, brachytherapy is the treatment of choice. When the lesion is located in the base of tongue, brachytherapy is a reasonable option.

Combined external irradiation and interstitial implantation for T1 and T2 epidermoid carcinomas of base of tongue: The creteil experience (1971–1981)

Forty-eight patients with T1 or T2 epidermoid carcinomas of the base of tongue were treated at the Henri Mondor Hospital between 1971 and 1981. Forty-one patients received moderate dose 60Co external beam irradiation (mean: 48.6 Gy) to the primary tumor and regional nodes, followed by an interstitial iridium 192 implant to the primary tumor (mean: 32 Gy). This completed the treatment for the 30 node negative patients, but those with clinically positive nodes were managed by either an additional electron beam boost to the involved nodes or a neck dissection. Seven tumors were treated exclusively by implantation to the base of tongue (mean: 63 Gy). Five-year crude disease-free survival is 50% with 35% of patients dying of recurrent disease. Definitive local control for T1 lesions is 85% (11/13) and for T2 is 71% (25/35). A dose response effect was observed with local control of 79% (26/33) obtained with a combined dose greater than or equal to 75 Gy, but only 50% (4/8) for less than or equal to 70 Gy. For N0 patients definitive regional control is 97% and for N1-3 is 89%. Minor or moderate soft tissue ulceration was observed in 12 patients, including 3 cases that progressed to osteonecrosis. None required surgical intervention. No correlation exists between necrosis and tumor size or total dose.

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

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

A HIGH AND SUSTAINED RESPONSE RATE IN REFRACTORY OR RELAPSING LOW-GRADE LYMPHOMA MASSES AFTER LOW-DOSE RADIATION: ANALYSIS OF PREDICTIVE PARAMETERS OF RESPONSE TO TREATMENT

PURPOSE To determine the efficacy of small doses of radiation in patients with recurrent or refractory low-grade lymphoma masses. METHODS AND MATERIALS Patients with refractory or relapsing low-grade lymphoma masses. The two largest diameters of the tumor mass were measured, whenever possible, before and after treatment. A dose of 4 Gy of radiotherapy was delivered to tumor sites in 2 fractions. Patients were evaluated for response 1-4 months later and at regular follow-up visits. RESULTS Forty-eight patients with low-grade lymphomas according to the working formulation received low-dose radiotherapy between March 1987 and November 1998. Most patients had advanced disease at the time of radiation treatment, and 80% had received at least two chemotherapy regimens before treatment. The median interval between the initial diagnosis and radiotherapy was 2.7 years (range 0-22 years). Low-dose radiation was delivered to 135 tumor sites. Nodal and extranodal tumor sites represented 80% and 20% of masses, respectively. An objective response was obtained in 81% of the sites, with 57% attaining a complete remission. The 2-year actuarial freedom from local progression (FFLP) rate was 56% (95% CI, 46-66%). Tumor masses </=5 cm in diameter had a significantly higher 2-year FFLP rate than larger masses (51% vs. 27%). It is noteworthy that the 2-year FFLP rate for patients treated with less than 2 chemotherapy regimens before radiotherapy was significantly higher than the 2-year FFLP rate for more heavily treated patients (96% vs. 48%). The 2-year FFLP rates for extranodal tumor sites and nodal sites were not significantly different. The tumor size (< or =5 cm vs. > 5 cm), the number of chemotherapy regimens (0-1 vs. more), and age at time of radiation treatment (< or =65 years or > 65 years) were significant predictive parameters of response to treatment. CONCLUSIONS In this retrospective study, low-dose radiation proved efficient, with long-lasting effects in the majority of patients with recurrent or refractory low-grade lymphomas. This simple and nontoxic treatment should be investigated prospectively in patients with advanced disease and a low tumor burden not immediately warranting chemotherapy.

Definitive radiation treatment for early stage carcinoma of the soft palate and uvula: the indications for iridium 192 implantation.

From 1971 to 1984 59 T1 and T2 carcinomas of the soft palate and uvula were treated definitively by irradiation at the Henri Mondor hospital. Included are ten patients previously irradiated to the oropharyngeal area for either a carcinoma of the soft palate or another malignancy. Sixteen patients were treated by external irradiation alone, 14 by Iridium 192 implantation, and 29 by a combination of the two. Two techniques of implantation were used: the guide gutter technique (33 patients) and the plastic tube technique (10 patients). Clinically negative neck nodes (51/59) either received prophylactic telecobalt therapy (39/51) or were surveilled (12/51). Clinically involved nodes (8/59) were managed either by external irradiation alone (4/8) or combined with neck dissection (4/8). Local failure was 25% (4/16) after exclusive telecobalt therapy, 18% (5/19) after combined telecobalt therapy and implantation, and 0% (0/14) after Iridium 192 implantation alone. No local failures were seen with the plastic tube technique (0/10) as compared to 15% (5/33) for guide gutters. Only two nodal failures were observed (2/59: 3%). Crude 5-year disease-free survival was 33%. Severe complications were limited to one osteonecrosis, one soft tissue necrosis, and one partial palatal incompetence. Salivary impairment was reduced when implantation was used for part or all of the treatment. We recommend 45 Gy external radiation followed by 30 Gy from Iridium 192 implantation using the plastic tube method unless there has been prior oropharyngeal irradiation, in which case we give 60 Gy from implantation alone. For clinically negative neck nodes, we recommend 45 Gy prophylactic external neck irradiation. For clinically positive lymph nodes, this should be followed by either a 25 to 30 Gy boost to the involved nodes or a neck dissection.

Central nervous system relapses after bone marrow transplantation for acute lymphoblastic leukemia in remission

This study defines the risk of central nervous system (CNS) relapse in patients undergoing bone marrow transplantation (BMT) for acute lymphoblastic leukemia (ALL) in remission, with no posttransplant prophylactic CNS therapy. Ninety‐two consecutive patients in complete remission received BMT for ALL (n=82) or high‐grade non‐Hodgkins lymphoma with poor prognostic factors at diagnosis (n=10). Sixtysix patients received allogeneic BMT (Allo‐BMT) and 26 patients, without an identical sibling, underwent autologous BMT (Auto‐BMT). Fifteen patients had CNS involvement at diagnosis and underwent BMT in first remission. Eight patients experienced CNS relapse after BMT, corresponding to a probability of 11% at 3 years. Apart from a history of prior CNS involvement, no patient characteristic evaluated statistically influenced CNS relapse after BMT. The probability of CNS relapse was 5.5% for the 70 patients without history of CNS involvement and 27.5% for the 22 patients with prior CNS involvement. However, subgroup analysis showed that the increased risk of CNS relapse is mainly observed in Auto‐BMT patients with history of prior CNS involvement, particularly in patients undergoing BMT in first remission (three of five Auto‐BMT versus one of ten Allo‐BMT). Taking into account the multiple factors which influence the occurrence and the treatment of CNS leukemia, the results on this retrospective study suggests that (1) for patients without CNS involvement at diagnosis and for whom BMT is performed in first remission, cranial irradiation before BMT and posttransplant prophylactic CNS therapy can be omitted because of the low probability of CNS relapse after BMT (3,4%), when total‐body irradiation (TBI) is included in the conditioning regimen; and (2) the difference observed between Allo‐BMT and Auto‐BMT patients with previous CNS involvement and undergoing BMT in first remission could indicate that graft‐versus‐host leukemia acts even in the CNS in Allo‐BMT patients.

The indications for total cutaneous electron beam radiation therapy of mycosis fungoides

From 1977 to 1984, we treated 34 patients with mycosis fungoides and 9 patients with B cutaneous lymphomas. Eighteen patients with mycosis fungoides were treated with total skin electron irradiation (TSEI) and had a minimum follow-up of 15 months (range 15 months to 7 years). The lowest electron energy of the linear accelerator was 8 MeV therefore we placed a plexiglas screen between the patient and the machine; the resulting electron energy was 4 MeV. The total dose was 30 Gy delivered in 12 fractions over 40 days. There were 8 males and 10 females. The median age was 48 years (ranging from 13 to 78 years). All patients were staged as follows: Stage A = superficial lesions covering less than 50% of the body surface; Stage B = superficial lesions covering more than 50% of the body surface; Stage C = tumors involving the skin, lymph nodes and/or visceral organs. Five patients with Stage A (5/5) and 5 patients with Stage B (5/5) had a complete remission, 1 stage A patient relapsed 6 months after completion of treatment. All the Stage B patients recurred between 3 and 15 months. The recurrences were localized to the skin and were well controlled with topical nitrogen mustard or puvatherapy. Among the Stage C patients, 3 did not respond to treatment and died of their disease; the remaining 5 patients achieved complete remission but they all relapsed from 2 to 9 months following completion of treatment. The median follow-up was 32 months and the average time for relapse was 6.5 months. All relapses except one (15 months) occurred within the first year. We feel that total skin electron irradiation is indicated in Stage A and B patients. However, we feel Stage C patients should receive TSEI for palliative purposes only.

Improving Survival in Patients Treated for a Lung Cancer Using Self-evaluated Symptoms Reported Through a Web Application

Objectives: We retrospectively compared survivals in patients with a lung cancer history and followed by the so-called sentinel Web-application that allows early detection of relapse and early palliative care initiation versus a conventional follow-up in our center. Methods: The survival in 98 consecutive patients with lung cancer was assessed. The first part of them (the control arm) was retrospectively recruited between March 2011 and August 2012. The second half of them (the experimental arm) was prospectively recruited between August 2012 and December 2013 to weekly fill a form of 11 self-assessed symptoms, then processed by the “sentinel” Web-application. Data were sent to this sentinel application in real-time between planned visits. An email alert was sent to the oncologist when self-scored symptoms matched some predefined criteria. Follow-up visit and imaging were then organized after a phone call for confirming the suspect symptoms. In the control arm (49 patients), a common follow-up was applied (visit and imaging every 2 to 6 mo according to stage of tumor and kind of treatment). Results: Median follow-up duration was 12.3 months in the experimental arm and 16.7 months in the control arm (P=0.27). Survival was significantly better in the sentinel arm than in the control arm (P=0.0014). Median survival was 16.7 months in the control arm and 22.4 months in the experimental arm. One-year survival was 86.6% in the experimental arm and 59.1% in the control arm. Conclusions: Survival may be improved by early detection of relapse and early palliative care initiation by using sentinel-like Web-application.

Interstitial pneumonitis and venocclusive disease of the liver after bone marrow transplantation.

One hundred and seventy patients were analysed for interstitial pneumonitis and 151 for venocclusive disease of the liver after bone marrow transplantation. We present our results with emphasis on the role of the parameters of single fraction total body irradiation.