Brachytherapy for soft tissue sarcomas. Technique and therapeutic indications]

The role of brachytherapy in the therapeutic strategy of soft tissue sarcomas has been difficult to assess due to the fact it has been during a long time institution-specific. However, the experience gained specially with low dose-rate treatments has allowed formulating guidelines for technical rules and patient selection. Brachytherapy used as an isolated treatment combined with surgery has proven to be effective in high-grade sarcomas, compared to surgery alone, in a unique randomized trial. Beside, a number of data have shown that the combination of brachytherapy and external beam irradiation could be superior to brachytherapy or external beam irradiation alone in the treatment of tumors with high-grade, or central location, locally advanced or on contact with neurovascular structures. Brachytherapy alone, combined with surgery, is of interest for conservative treatment of recurrent sarcomas occurring in previously irradiated areas. The occurrence of side effects remains acceptable if technical guidelines are followed, for surgery as well as for brachytherapy, using the most modern available treatment techniques. Brachytherapy should be at the moment an integrated part of the multidisciplinary treatment of soft tissue sarcomas.     

Surgery of far-advanced colorectal cancer--extension of surgical indications and its results

As there has been much progress in pre- and post-operative management, the safety of aggressive surgery has been improved, making this approach more widely available. Total pelvic eviscerations were performed for fifty-one patients with far-advanced rectal cancer which involved adjacent organs. The results were a 33% 5-year survival rate and 2 operative deaths. Even for patients with distant metastasis elsewhere, total pelvic evisceration may be acceptable for the good control of local pelvic symptoms (severe pain, infections, etc.). This operation is not, however, indicated for cases in which complete removal of the cancerous mass seem to be impossible. For advanced rectal cancer with a high degree of lymph-node metastasis, extension of lymph-node dissection up to the para-aortic region or ileo-pelvic lateral dissection en bloc with the internal iliac vessels were effective for decreasing the incidence of local recurrence. For forty-nine patients with liver metastasis, radical surgery with removal of liver metastatic lesions was carried out and the resulting 5-year survival rate was 30%. Removal of pulmonary metastatic lesions was also performed in thirty-four patients and the 5-year survival rate was 45%. The surgical results were poor in cases of multiple metastatic lesions in the liver or lung or of peritoneal dissemination. Extended surgery for far-advanced colorectal cancer may thus be actively undertaken unless multiple metastatic lesions are present.     

局部晚期结直肠癌联合脏器切除的适应证和治疗策略的选择

联合脏器切除手术是局部晚期结直肠癌唯一可能治愈的手段,随着手术技术、治疗理念以及各类靶向药物研发的进步,局部晚期结直肠癌治疗手段愈加多样化,如何选择合理的治疗策略是当前临床医生面临的常见问题。     

Breast cancer: limited excision followed by irradiation. Results and therapeutic indications in 150 cases treated at the Curie Foundation in 1960-1970

The authors studies 150 cases of mammary cancer treated at La Fondation Curie between 1960 and 1970 by lumpectomy followed by irradiation. At the 5th year the survival rate without recurrence is 85 p. 100 (128 out of 150 cases) and is 72 p. 100 (56 out of 78) at the 10th year. There were 17 local/regional recurrences in the first 5 years, say 11 p. 100, of which one was supraclavicular and one "acute". Of the 15 cases operated on 7 are alive without sign of recurrence at more than 5 years. Satisfactory conservation of the breast has been achieved since in the 128 cured patients the breast was preserved 123 times (96%). In the 78 cases followed for 10 years there were 13 local/regional recurrences, say 17 p. 100, of which one was "acute". In the 56 cured cases the breast was preserved in 49 (87%). The combination of lumpectomy/irradiation seems to be a viable therapeutic modality but with these limitations: 1. That the diagnosis of carcinoma should be pre- or per-operative and the lumpectomy generous. 2. That the radiotherapy dosage should be relatively moderate. 3. That the indications be strictly adhered to--only treat tumours less than 3 cm, taking due note of the respective volumes of tumour and breast without apparent involvement of axillary nodes. If these conditions are adhered to the results are good both aesthetically and curatively.     

Radiotherapy of benign dermatoses: indications, practice, and results.

Limited indications for radiation treatment of benign dermatoses are presented in order to emphasize modern restrictions and techniques in the use of dermatologic radiation therapy and to promote measures of protection against stray radiation. The use of softer, less penetrating X rays, least effective doses and meticulous shielding are recommended. So done, radiation therapy offers an effective therapeutic alternative for conditions that do not respond to other forms of treatment.     

Surgical treatment for metastatic malignancies. Pulmonary metastasis: indications and outcomes

Surgical resection is an important modality in the treatment of pulmonary metastases from various solid tumors. The criteria for pulmonary metastasectomy are as follows: (1) the patient must be a good risk for surgical intervention; (2) the primary malignancy is controlled; (3) there is no other, extrapulmonary, metastasis; and (4) the pulmonary lesions are thought to be completely resectable. The appropriate selection of candidates according to these criteria leads to an overall 5-year survival after pulmonary metastasectomy of about 30%–40%. However, most of the reported results are retrospective analyses, and the significance of pulmonary metastasectomy seems to vary according to the primary malignancy. To clarify the significance of surgical treatment for pulmonary metastases, we need further analysis of various prognostic factors, with special reference to each primary malignancy, as well as a multiinstitutional study, and randomized prospective studies, if possible.     

Endobronchial brachytherapy: technique and indications]

The endobronchial brachytherapy procedure involves the insertion of an afterloading catheter into bronchus in close proximity to an endoluminal lesion, and to perform limited irradiation sparing as much as possible normal health tissues. The catheter is inserted during a classical flexible bronchoscopy. Three types of indications have been discussed: (i) palliative treatment of lung carcinoma, with or without laser desobstruction: an improvement in respiratory symptoms was observed in 60 to 80% of the cases; (ii) curative treatment for localised endobronchial carcinomas, in previously irradiated patients, or in case of contraindication of surgery or external beam irradiation; local control rate range from 60 to 70% at 2 years; (iii) combination of external irradiation and brachytherapy in the first line treatment of lung cancers. Two randomised trials did not show any improvement in survival for this approach; however, they have included advanced diseases. In the opposite, this association seems very effective for early stage lung carcinomas. Two major complications were regularly reported, haemoptysis and radiation bronchitis. Predictive factors for these toxicities are actually better known: haemoptysis could be due to a progressive disease more often than to brachytherapy itself; technical factors (dose, volume, fractionation), however, could explain a number of radiation bronchitis, and their incidence could decrease in the future.     

Radiochirurgie fonctionnelle : indications et perspectives

Stereotactic radiosurgery (SRS) is a non-invasive technique that enables to create brain focal lesions with a high precision and localization. Thus, functional brain disorders can be treated by SRS in case of pharmacoresistance or inoperability. To date, treatment of trigeminal neuralgia is the most described and known indication. Other indications will be developed in the future like movement disorders, refractory epilepsy, obsessive compulsive disorder and severe depression. We present here a review of actual and future indications of functional brain SRS with their level of evidence. All these SRS treatments have to be strictly conducted by trained teams with an excellent collaboration between radiation physicists, medical physicists, neurosurgeons, neurologists, psychiatrists and probably neuroradiologists.     

Extramedullary plasmacytoma: tumor occurrence and therapeutic concepts.

BACKGROUND: Extramedullary plasmacytoma (EMP) is a rare entity belonging to the category of non-Hodgkin lymphoma. EMPs make up 4% of all plasma cell tumors and occur mainly in the upper aerodigestive tract (UAD). Seven patients with EMP included in this evaluation were under the authors' care and have been clinically followed since 1990. Because there are no general guidelines for the treatment of patients with EMP, the authors tried to obtain detailed data about the occurrence of this disease and also reviewed the therapies that have been used. To do so, they evaluated all EMP cases published in the medical literature until now and included their own experience. METHODS: Based on the clinical course and follow-up of their own EMP patients, the authors evaluated and reinvestigated all EMP cases cited in MEDLINE, Index Medicus, DIMDI (Deutsches Institut fur medizinische Dokumentation und Information, Cologne, Germany), and the reference lists of the publications found through these sources. RESULTS: In a detailed literature search, more than 400 publications between 1905 and 1997 were found, and these revealed that EMP mainly occurs between the fourth and seventh decades of life. Seven hundred fourteen cases (82.2%) were found in the UAD, and 155 cases (17.8%) were found in other body regions. The following therapeutic strategies were used to treat patients with EMP of the UAD: radiation therapy alone in 44.3%, combined therapy (surgery and radiation) in 26.9%, and surgery alone in 21.9%. The median overall survival or recurrence free survival was longer than 300 months for patients who underwent combined intervention (surgery and radiation). This result was statistically highly significant (P = 0.0027, log rank test) compared with the results for patients who underwent surgical intervention alone (median survival time, 156 months) or radiation therapy alone (median survival time, 144 months). In most cases of non-UAD EMP, surgery was performed (surgery alone, 55.6%; surgery and radiation combined, 19.8%; radiation alone, 11.1%), but there were no statistical differences in survival (P = 0.62). Overall, after treatment for EMP in the UAD, 61.1% of all patients had no recurrence or conversion to systemic involvement (i.e., multiple myeloma, MM); however, 22.0% had recurrence of EMP, and 16.1% had conversion to MM. After treatment for EMP in non-UAD areas, 64.7% of all patients had no recurrence or MM, 21.2% had recurrence, and 14.1% had conversion to MM. CONCLUSIONS: The current investigation provides evidence that surgery alone gives the best results in cases of EMP of the UAD when resectability is good. However, if complete surgical tumor resection is doubtful or impossible and/or if lymph node areas are affected, then combined therapy (surgery and radiation) is recommended. These results, which were obtained from retrospective studies, should be confirmed in randomized trials comparing surgery with combined radiation therapy and surgery.