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Purpose To analyze the efficacy, toxicity, and pattern of relapse after adjuvant cisplatin-based chemotherapy followed by three-dimensional irradiation and concomitant LV5FU2 chemotherapy (high-dose leucovorin and 5-fluorouracil bolus plus continuous infusion) in the treatment of completely resected high-risk gastric cancer. Methods and Materials This was a retrospective analysis of 52 patients with high-risk gastric cancer initially treated by total/partial gastrectomy and lymphadenectomy between January 2002 and June 2007. Median age was 54 years (range, 36–75 years). Postoperative treatment consisted of 5-fluorouracil and cisplatin chemotherapy. Adjuvant chemotherapy was followed by three-dimensional conformal radiotherapy in the tumor bed and regional lymph nodes at 4500 cGy/25 fractions in association with concomitant chemotherapy. Concomitant chemotherapy consisted of a 2-h infusion of leucovorin (200 mg/m²) followed by a bolus of 5-fluorouracil (400 mg/m²) and then a 44-h continuous infusion of 5-fluorouracil (2400–3600 mg/m²) given every 14 days, for three cycles (LV5FU2 protocol). Results Five-year overall and disease-free survival were 50% and 48%, respectively. Distant metastases and peritoneal spread were the most frequent sites of relapse (37% each). After multivariate analysis, only pathologic nodal status was significantly associated with disease-free and overall survival. Acute toxicities were essentially gastrointestinal and hematologic. One myocardial infarction and one pulmonary embolism were also reported. Eighteen patients had a radiotherapy program interruption because of acute toxicity. All patients but 2 have completed radiotherapy. Conclusion Postoperative cisplatin-based chemotherapy followed by conformal radiotherapy in association with concurrent 5-fluorouracil seemed to be feasible and resulted in successful locoregional control.

Resume Le cancer bronchique est le plus meurtrier au monde. Environ 80–85 % sont des carcinomes bronchiques non a petites cellules. Plus d’un tiers sont diagnostiques alors qu’ils sont localement evolues. A ce stade, le traitement de reference reste la chimioradiotherapie concomitante pour les patients en bon etat general. En depit des progres de ces dernieres annees, le pronostic des carcinomes bronchiques non a petites cellules reste defavorable avec des taux eleves de recidives locale et metastatique. L’heterogeneite des anomalies moleculaires presentees par les carcinomes bronchiques non a petites cellules et la connaissance approfondie de ces cibles potentielles est une source prometteuse de developpement de nouveaux agents pharmacologiques. Cet article fait une mise au point sur les voies les plus etudiees, mais aussi celles particulierement prometteuses dans le traitement des bronchiques non a petites cellules localement evolues inoperables. Les etudes les plus avancees en association a la radiotherapie portent sur l’inhibition de la voie d’epidermal growth factor receptor (EGFR) par anticorps monoclonaux et inhibiteurs de tyrosine kinase, et l’inhibition de l’angiogenese. L’essor de ces therapies ciblees permet d’envisager le developpement de combinaisons therapeutiques personnalisees adaptees aux caracteristiques tumorales intrinseques. La modulation pharmacologique de la radiosensibilite par les therapies ciblees n’en est qu’a ses debuts mais offre deja des perspectives encourageantes.

Resume Objectif de l’etude Evaluation de la probabilite de survie sans rechute biochimique apres radiotherapie de rattrapage selon les definitions de l’American society for therapeutic radiology and oncology (Astro) et de Phoenix, chez des patients ayant une persistance ou une elevation secondaire de la concentration serique de PSA, apres prostatectomie pour un cancer de la prostate. Patients et methodes Analyse retrospective des dossiers de 59 patients traites entre 1990 et 2003 par irradiation pour une recidive biochimique apres prostatectomie. Il a ete delivre une dose mediane de 66 Gy dans le lit de prostatectomie par radiotherapie bidimensionnelle ou tridimensionnelle. Le critere principal de jugement de l’efficacite etait la probabilite de survie sans rechute biochimique selon les definitions de l’Astro et de Phoenix (nadir + 2 ng/ml). Resultats Avec un suivi median de 38 mois, la probabilite de survie sans rechute biochimique a trois ans etait selon les criteres de l’Astro de 60 %, elle etait de 72 % selon la definition de Phoenix. Selon l’analyse unifactorielle, une concentration serique de PSA ≥ 1 ng/ml avant la radiotherapie et un envahissement des vesicules seminales etaient associes a un risque de recidive biochimique. Selon l’analyse multifactorielle, seule une concentration serique de PSA ≥ 1 ng/ml avant la radiotherapie reste predictive pour une recidive biochimique, quelle que soit la definition. Conclusion La radiotherapie de rattrapage est un traitement efficace apres prostatectomie, que l’on utilise la definition de l’Astro ou celle de Phoenix. Seule une concentration serique de PSA ≥ 1 ng/ml avant la radiotherapie est predictive pour la recidive biochimique.

As compared to conventional axillary dissection, the sentinel node technique is accompanied by reduced morbidity and shorter hospital stay. Based on available data, the use of this technique does not seem to yield higher rates of axillary recurrence. A combination of both radioisotope detection and blue dye increases the identification rate, while also reducing false-negative rate. Surgical results are optimized when preoperative lymphoscintigraphy mapping is obtained in addition to peroperative probe detection. Considering the site of injection, the subareolar injection can be easy to apply even in case of non-palpable tumours, and gives higher count rates. However, the intraparenchymal, peritumoral, injection is necessary to evidence cases of extra-axillary drainage (internal mammary, infra- or supraclavicular) that is present in about 20% of patients. With the advent of hybrid cameras (SPECT-CT), the topography of these extra-axillary nodes can be given with high precision. Use of the sentinel node technique has been accompanied by an increase in the percent of patients with node involvement, due to an increased detection of micrometastases inferior or equal to 2 mm. Following an overview of basic principles, and of the main results with the sentinel node technique we focus the discussion on several points that are still open to debate, such as: 1) which group of patients can benefit from the sentinel node technique? 2) What is the optimal methodology? 3) What is the prognostic significance of micrometastases and of isolated tumour cells? 4) What attention should be given to extra-axillary drainage?

Resume Objectif de l’etude Etude de la faisabilite et des resultats d’une chimiotherapie adjuvante suivie d’une chimioradiotherapie realisee selon une technique conformationnelle chez des patients operes pour un adenocarcinome gastrique. Patients et methodes Vingt-six patients ont recu apres une chirurgie radicale (classee R0 ou R1) trois cycles de 5-fluoro-uracile et cisplatine, puis une chimioradiotherapie associant le protocole LV5FU2 et une radiotherapie de 45 Gy. Resultats Soixante-dix-sept pour cent des patients etaient atteints d’un cancer classe pT3 ou pT4 et les ganglions ont ete classes pN1 dans 54 % des cas et pN2 dans 31 %. Faisabilite Il a ete observe durant la chimiotherapie adjuvante, qui a pu etre menee a son terme dans tous les cas sauf un, des nausees ou des vomissements de grade II ou III chez 12 patients (48 %) et une neutropenie de grade III ou IV chez deux patients. Il a ete observe pendant la chimioradiotherapie des nausees ou vomissements de grade II ou III chez dix patients, une diarrhee de grade II ou III chez deux et une œsophagite de grade II ou III chez deux. Tous les patients, sauf un, ont recu la dose prevue de 45 Gy. La radiotherapie a ete interrompue chez six patients pendant en moyenne 14 jours. Apres un suivi moyen de 30 mois, 65 % des patients etaient en vie sans rechute et la duree mediane de survie etait de 32 mois. Conclusion Ce schema parait faisable et permet d’intensifier la chimiotherapie postoperatoire par rapport au schema de type Macdonald. Son benefice clinique reste a evaluer dans une etude de phase III.

Results of surgery in locally advanced esophageal carcinomas (T3 and/or N1) are disappointing. Concomitant chemoradiotherapy (RTCT) gave equivalent survival results in many phase II studies. Two randomized trials (French and German) compared surgery or additional RTCT after a first phase of RTCT. Both drew the same conclusions, that is surgery did not improve overall survival but increased postoperative mortality. However, local control was found better in the surgical arms, and in some subgroups, esophagectomy improved disease-free survival suggesting that some patients may benefit from surgery. After preoperative RTCT, absence of residual disease in the surgical specimen (pathological complete response) occurs in 15 to 30%; these patients underwent a radical surgery without any benefit but with high risk of morbidity and mortality. Nevertheless, it is still difficult to select this sub-population: CT-scan or endoscopy with biopsies have a low sensitivity and specificity. 18-FDG-PET-scan, performed after or during the RTCT, is able to increase sensitivity, but only preliminary results with small populations are available. No biological factor of chemoradiosensitivity (p53, NfkappaB, p21...) could predict who will respond or not. Another approach is to reserve surgery only to patients with a demonstrated local failure (salvage surgery) but the feasibility of this technique is still debated. Finally, local relapses are frequent after RTCT and optimisation of the current schedules is mandatory to improve oncologic results. Unfortunately, increasing the radiation dose did not improve local control and showed more toxicities. New drugs as taxanes, oxaliplatine, or targeted therapies are tested in on-going phase III trial.

Postoperative radiotherapy after breast surgery increases overall survival by decreasing the local relapse rate. The main site of relapse is the breast or the chest wall. The value of irradiation of the nodal basins is still discussed. It must be emphasized that nodal areas were systematically irradiated in the postmastectomy randomized trials demonstrating a benefit in survival for adjuvant radiotherapy. Axillary relapses are infrequent in case of complete axillary dissection; complementary irradiation could be proposed if the axillary dissection is incomplete or if there is a massive pathologic involvement of the axilla. Its main complication is lymphoedema, which remains the most frequent sequellae of the treatment of breast cancer. Supraclavicular irradiation is logical in case of axillary involvement. Internal mammary nodes are involved in 20 to 40% of the patients, depending of the axillary involvement and location of the tumor inside the breast. Irradiation of the internal mammary basin is difficult: optimal dosimetry required a CT-based simulation. Its benefit remains to be proved. Internal mammary nodes irradiation probably increased cardiovascular mortality. Sophisticated techniques are needed to spare the heart from irradiation. Two large randomized trials (French group, European Organization for Research and Treatment of Cancer [EORTC]) are currently evaluating the possible benefit of internal mammary irradiation.

Tres estudios aleatorizados recientes han demostrado un beneficio, en terminos de supervivencia sin progresion biologica y clinica, de la radioterapia adyuvante tras una prostatectomia, en los pacientes con riesgo de recidiva local como una afectacion extracapsular, una invasion de las vesiculas seminales o margenes de exeresis positivos. Sin embargo, estos tres estudios han comparado una radioterapia adyuvante con una actitud de vigilancia, y no con la administracion precoz de radioterapia en caso de recidiva biologica, es decir, con una concentracion de antigeno prostatico especifico (PSA) muy baja (por ejemplo, ≤ 0,6 ng/ml) sin signos clinicos de la enfermedad, lo que expone a una parte de estos pacientes a un riesgo de sobretratamiento con un riesgo de complicacion. Varios estudios retrospectivos han demostrado el beneficio, en terminos de control biologico, de una radioterapia de rescate en caso de reelevacion del PSA tras una negativizacion inicial del PSA postoperatorio, la cual es mas eficaz cuanto mas precoz sea. Sin embargo, a la vista de los estudios controlados que favorecen la radioterapia adyuvante, esta se convierte en el tratamiento estandar tras la prostatectomia si existen factores de riesgo de recidiva local (margenes positivos, afectacion extracapsular o de las vesiculas seminales). En la actualidad se estan realizando varios estudios aleatorizados para definir el papel que ocupa la radioterapia diferida respecto a la radioterapia adyuvante.

A number of retrospective and prospective studies have demonstrated that radiotherapy of prostate cancer must be actually conformal. Three-dimensional (3D) treatment planning consists in an as accurate as possible definition of target-volume, usually by CT-scan, and design of radiation fields shaped to this target-volume. Several steps are required, each step being important for the overall quality of the treatment. Conformal radiotherapy is better tolerated than conventional irradiation, with significantly less rectal toxicity. It allows dose-escalation up to 80 Gy. It is now possible to go beyond this dose with intensity-modulated radiotherapy. The benefit of these high doses was demonstrated by some large retrospective studies and some prospective dose-escalation trials. Several randomized trials are in progress, preliminary results of two of them have been published, both showing an improvement in disease control with the higher doses. The advantage of higher doses is clearly evident for patients in the intermediate prognostic group, but is still discussed for patients with a low risk tumour or treated in combination with hormone therapy. Late proctitis is the main toxicity of these high doses. Some volume constraints have been defined during the last years and will allow a decrease of the rate of rectal toxicity. Because of these technological improvements, results of radiation therapy are now similar to those of surgery: no direct comparison with a randomized trial is available, but large comparative studies show that long-term disease control are identical with both techniques. Radiation therapy must be proposed to all patients with a prostate carcinoma as an alternative to surgery.

Purpose: To evaluate outcomes after high-dose-rate endobronchial brachytherapy (HDR-EBBT) for limited lung carcinoma. Methods: A total of 106 patients with endobronchial lung cancer and not eligible for surgery or external beam radiotherapy, without nodal or visceral metastases, were treated with HDR-EBBT. They had developed disease relapse after surgery ( n = 43) or external beam radiotherapy ( n = 27) or had early lung cancer with respiratory insufficiency ( n = 36). Treatment consisted of six fractions of 5 or 7 Gy, usually delivered 1 cm from the source. Results: The complete histologic response rate, evaluated at 3 months after HDR-EBBT, was 59.4%. At 3 and 5 years, the local control, overall survival, and cause-specific survival rates were 60.3% and 51.6%, 47.4 and 24%, and 67.9 and 48.5%, respectively. Factors significantly associated with local failure were high tumor volume (tumor length >2 cm, bronchial obstruction >25%, tumor visibility on CT scan) and previous endoscopic treatment. Cause-specific survival, but not overall survival, was significantly associated with local control, probably because of the high rate of deaths not related to lung cancer. Five deaths were attributed to the HDR-EBBT procedure (two from fatal hemoptysis and three from bronchial necrosis). Conclusion: High-dose-rate-EBBT achieved a long-term cause-specific survival rate of 50% of the patients with localized endobronchial carcinoma and could be considered curative.

A number of retrospective and prospective studies have demonstrated that radiotherapy of prostate cancer must be actually conformal. Three-dimensional (3D) treatment planning consists in an as accurate as possible definition of target-volume, usually by CT-scan, and design of radiation fields shaped to this target-volume. Several steps are required, each step being important for the overall quality of the treatment. Conformal radiotherapy is better tolerated than conventional irradiation, with significantly less rectal toxicity. It allows dose-escalation up to 80 Gy. It is now possible to go beyond this dose with intensity-modulated radiotherapy. The benefit of these high doses was demonstrated by some large retrospective studies and some prospective dose-escalation trials. Several randomized trials are in progress, preliminary results of two of them have been published, both showing an improvement in disease control with the higher doses. The advantage of higher doses is clearly evident for patients in the intermediate prognostic group, but is still discussed for patients with a low risk tumour or treated in combination with hormone therapy. Late proctitis is the main toxicity of these high doses. Some volume constraints have been defined during the last years and will allow a decrease of the rate of rectal toxicity. Because of these technological improvements, results of radiation therapy are now similar to those of surgery: no direct comparison with a randomized trial is available, but large comparative studies show that long-term disease control are identical with both techniques. Radiation therapy must be proposed to all patients with a prostate carcinoma as an alternative to surgery.

La radioterapia actual del cancer de prostata solo puede ser conformacional. Consiste en la localizacion de la prostata mediante tomografia computarizada y en una adaptacion lo mas precisa posible de los haces de irradiacion al volumen-diana. Requiere una sucesion de etapas tecnicas cuya practica exacta condiciona la calidad del conjunto. Esta tecnica ha demostrado una mejor tolerancia que la radioterapia convencional, con menos efectos secundarios de manera significativa, en especial rectales. Permite aumentar las dosis sobre la prostata hasta un valor de 80 Gy. Este umbral de 80 Gy sera superado probablemente por la radioterapia de intensidad modulada. El beneficio de las dosis elevadas se ha demostrado en importantes estudios prospectivos de ajuste progresivo de la dosis. Dos ensayos aleatorizados publicados se situan tambien a favor de las dosis elevadas, y existen otros en desarrollo. La utilidad de las dosis elevadas estaria demostrada en los pacientes de los grupos intermedios. Es motivo de discusion en los pacientes con riesgo bajo, o bien en los tratados en asociacion con la hormonoterapia. La toxicidad principal es rectal; de manera progresiva, se han demostrado imposiciones volumetricas que, en el futuro, deberian permitir disminuir aun mas dicha toxicidad. Gracias a los progresos realizados con la tecnica conformacional, los resultados obtenidos son similares a los de la cirugia en terminos de control de la enfermedad, como se ha demostrado en varias series comparativas. Por tanto, la radioterapia se ha convertido en una alternativa real a la cirugia y debe proponerse a todo paciente con cancer de la prostata.

Initially, preoperative chemotherapy had three aims, to improve the overall survival by an early exposure to systemic therapy, to evaluate in vivo the efficacy of chemotherapy and to monitor post-operative treatment, and to increase the rate of breast-conserving treatments. Eight randomised trials have been published. The general consensus about the results of these trials is that neoadjuvant chemotherapy did not improve overall survival, in comparison with an adjuvant treatment. Clinical and especially pathological complete response rates were correlated with the outcome of the patients and could be considered as an independent prognostic factor. Primary chemotherapy is a powerful tool to study the predictive factors, especially biological factors, of chemosensitivity. However, the usefulness of this approach to adjust post-operative treatments remains to be demonstrated. Finally, primary chemotherapy slightly increased the rate of breast conserving treatments, but is accompanied by a small increase in the risk of local recurrence. To propose a conservative treatment to a woman initially not suitable for a lumpectomy needs clear information about this enhanced risk.

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.

Resume La rechute biochimique, apres prostatectomie, n’est pas exceptionnelle, touchant selon les series 20 a 40 % des malades operes. Pour la prevenir, certains associent a la chirurgie une irradiation adjuvante, immediatement apres la chirurgie. Aucune etude de phase III n’est venue confirmer cette attitude. Les indications preferentielles d’une irradiation adjuvante sont une extension extra-capsulaire pluri-focale et l’atteinte des tranches de section, retrouvee sur plusieurs niveaux de coupe. L’analyse des series historiques laisse a penser que, dans ce cas, le controle biochimique de la maladie est ameliore. Plutot que d’irradier immediatement apres la chirurgie, d’autres preferent atteindre la reascension du PSA, afin de ne pas surtraiter certains patients. La radiotherapie, dite alors de sauvetage, donne 40 a 70 % de normalisations du PSA, mais elle ne semble reellement efficace que si la concentration serique de PSA est faible au moment du traitement. La radiotherapie differee n’est donc justifiee, en cas de facteurs de risque de recidive locale, que sous couvert d’une surveillance rapprochee du PSA apres la chirurgie. Dans tous les cas, il est important d’essayer de differencier risque de rechute locale et de dissemination metastatique : il est clair qu’une atteinte ganglionnaire histologiquement prouvee au moment de la chirurgie est plutot le signe de la presence de micro-metastases. Ceci semble egalement etre le cas si les vesicules seminales sont atteintes sur la piece operatoire, quoique ceci reste a confirmer.

Background: To evaluate the results of chemoradiotherapy with or without surgery in locally-advanced esophageal carcinomas (T3 and/or nodal involvement). Methods: One hundred twelve patients with locally-advanced carcinoma of the esophagus without histologically proven invasion of the tracheobronchial tree or distant visceral metastases were treated with concomitant chemoradiotherapy followed by re-evaluation; surgery was performed or chemoradiotherapy continued, based on tumor regression and the patient's general status. Chemoradiotherapy consisted of concomitant 5-fluorouracil (5FU)(1 g/m 2 day 1–3), cisplatinum (50 mg/m 2 day 1 and 2), and external beam irradiation up to a dose of 40 or 43.2 Gy. After a 4-week rest period, radical esophagectomy or a new cycle of chemoradiotherapy (up to a total dose of 65 Gy) was performed. Results: A complete clinical response was obtained in 25.7% of the patients and a partial response in 45.9%. Fifty patients underwent surgery, but only 38 patients had an esophagectomy. Post-esophagectomy mortality was 5.3%. A complete histologic response rate of 23.7% was obtained. Two- and 5-year survival rates were, respectively, 41.5% and 28.6% for the whole population. According to multivariate analysis, prognostic factors for survival were Karnofsky index, esophagectomy, and response to chemoradiotherapy. Five-year survival for patients who experienced a partial response to radiation and chemotherapy was 49.1% for those who had surgery and 23.5% for those treated without surgery ( p = 0.003). There was no obvious benefit for the small number of patients treated surgically after complete response to radiation and chemotherapy. Toxicity, essentially hematologic, was moderate. Conclusion: For locally-advanced esophageal carcinomas, esophagectomy, after concomitant chemoradiotherapy, could improve the survival rate, especially for patients who responded partially to the latter.

Resume But du protocole Le pronostic des cancers bronchiques localises au thorax mais inoperables reste sombre. Nous avons realise une etude de phase II de radio-chimiotherapie concomitante avec pour but d'ameliorer le controle local et la survie sans metastases a distance. Materiel et methodes Trente neuf patients ont ete inclus dans cette etude (dont 3 femmes; âge moyen: 56 ans). Quatre-vingt quinze pour cent avaient un bon etat general (indice de l'OMS 0 ou 1); il s'agissait d'un carcinome epidermoide dans 64 % des cas. On denombrait une tumeur de stade 1, 9 de stade IIIA, 24 de stade IIIB et 2 de stade inconnu. Le protocole consistait en des cycles de trois semaines de cisplatine (CDDP) (50 mg/m2 a j1 et j2) 5-fluoro-uracile (5FU) (1 gr/m2 a j1, j2 et j3 en perfusion continue) et de radiotherapie externe (20 Gy en dix fractions de j1 a j12), avec un repos therapeutique la 3e semaine. Resultats La tolerance du traitement a ete dans l'ensemble satisfaisante, il a ete observe une leucopenie de grade 3 ou 4 dans 15 % des cas, une thrombopenie de grade 3 ou 4 dans 3 % des cas, des nausees ou des vomissements de grade 3 ou 4 dans 15 % des cas. Nous n'avons pas note d'œsophagite majeure. La dose de chimiotherapie a pu etre respectee dans plus de 90 % des cycles. Une reponse objective a ete obtenue chez 56 % des patients, avec seulement 3 % de reponses completes. Cependant, l'evaluation etait faite en moyenne 6 semaines apres la fin du traitement et la fibrose post-radique a pu gener l'interpretation des images. La mediane et les taux de survie a 2 et 3 ans etaient respectivement de 11,4 mois, 27 % et 14 %. Le seul facteur pronostique retrouve etait l'indice d'etat general de l'OMS. La reponse radiologique n'etait pas un critere pronostique. Les modes de rechute ont ete analyses chez 20 patients: rechute locale isolee: 6 cas; metastases: 13 cas; association des deux: 1 cas. Conclusion Les associations concomitantes 5-FUCDDP et radiotherapie externe semblent realisables en pratique quotidienne. L'evaluation doit porter sur la survie et non sur la reponse radiologique. Une amelioration du controle local semble egalement realisable avec ce type d'association.

Resume But de l'etude Une obstruction tumorale endobronchique est frequemment notee au cours de l'evolution des cancers bronchiques, et peut etre responsable de symptomes gravissimes. Les patients peuvent se voir proposer une desobstruction bronchique pour laquelle plusieurs techniques sont aujourd'hui disponibles. Patients et methodes Une curietherapie endobronchique a ete realisee chez 149 malades. Soixante treize malades ont ete traites dans une optique curative, 47 dans un but palliatif et 29 ont recu une irradiation endobronchique en complement d'une irradiation externe. Le traitement consistait en series, repetees tous les 15 jours, jusqu'a un maximum de trois series, comportant deux seances a 24 h d'intervalle, delivrant chacune une irradiation de 7 Gy a 1 cm du catheter. Resultats Tous signes fonctionnnels confondus, 79 % des patients ont beneficie d'un effet palliatif sur leur Symptomatologie. Cent trente-deux patients ont eu une evaluation par endoscopie 2 mois apres le traitement; 64 tumeurs (48,5 %) etaient en remision histologique complete. La mediane de survie etait de 14,4 mois pour les patients traites a visee curative. L'obtention d'une remission histologique permettait de predire une survie plus longue (mediane de survie: 26,5 mois). Onze hemoptysies massives et 13 bronchites radiques ont ete observees. Conclusion Ces resultats confirment la faisabilite et les bons resultats de l'irradiation endobronchique sur ce terrain et incitent a promouvoir la realisation d'essais multicentriques controles, afin que soit precisee la place de la curietherapie endobronchique dans la strategie therapeutique des cancers bronchiques.

Between January 1973 and December 1984, 55 patients with prior irradiation of the oropharynx underwent salvage irradiation for recurrent (26 patients) or second cancers (29 patients) of the base of tongue. The initial irradiation had delivered from 45 to 80 Gy to the base of tongue. One of two techniques of Iridium implantation was used for salvage. Single course implants, delivering 60 Gy, were used until June 1981 in a total of 31 patients. After June 1981, split course implants with a source shift were used in 24 patients in the hope of decreasing treatment complications. The first and second course of the split course implants delivered 35 and 30 Gy, respectively, at a 1-month interval. The active lines of the second implant were placed parallel to and between the position of the lines of the first implant. This shift in the source position resulted in a more uniform dose within the treated volume with a 60% reduction in the high dose sleeves. The overall 3-year survival was 19% (28% T less than or equal to 3 cm). The overall local failure rate was 45.5% (25/55). The difference between the local failure rate after single course implants (52%) and after split course implants (37.5%) was not statistically significative. The response observed after the first course of a split course implant proved to be a reliable indication of the probability of achieving local control after a full course of treatment: 2/14 failures (14%) if the response was greater than or equal to 75% versus 7/10 (70%) if the response was less than 75% (p less than 0.01). The only complication noted in the 40 patients achieving immediate local control after either implant technique was mucosal necrosis. The introduction of split course implants was followed by a two and a half fold decrease in the incidence of necrosis: 43% (9/21) in the single course group and 16% (3/19) in the split course group (p = 0.05). Interstitial brachytherapy offers an effective and reasonable option for salvage therapy in patients with recurrent and second cancers occurring in the base of tongue even when the tumor arises in a zone that has previously received high dose irradiation. The use of split course implants with a shift in the position of the active lines at the time of the second implant significantly decreases the risk of radionecrosis.

L’interet du complement de dose apres radiotherapie externe (RTE) a ete demontre chez la plupart des patients. Nous rapportons notre experience de la curietherapie a haut debit de dose dans cette indication.

We have reviewed the evolution of our patients experiencing a local relapse after conservative treatment. Population 1183 pts have been treated with a combination of limited surgery and radiotherapy. 89 local relapses (LR) have been observed, for a 10-years local control rate of 83%. All the LR except two were invasive. 11% were inflammatory, 4 pts have metastasis at the time of LR diagnosis. Only 15 pts have had an axillary dissection, 10 pts with positive nodes. An extensive intraductal component was found in 46% of cases, vascular invasion in 35%. In 64% of cases, location of the LR was in the same quadrant as the initial tumor. 86% of the pts have been treated with a mastectomy; for 3 pts a second conservative treatment have been attempted; 45% of the pts have received chemotherapy. Results Survival for the whole population was 94% and 87% at 5 and 10 years. For patients experiencing a LR, 91% and 76% (P = 0.005). More metastatic disease occurred in the patients with a LR (36% vs 13%; P Conclusion Local relapse after breast conservative treatment is an indicator for a future metastatic dissemination. Early local relapse seems to have an especially bad prognostic, and are good candidates for adjuvant chemotherapy.

Brachytherapy is now a widely accepted palliative method for desob-structing the bronchial lumen. However, its place as a curative treatment is still debated. We have tried to distinguish between patients who can be cured with endobrachytherapy and palliative treatments. We report here the results of such a distinction. Definition of therapeutic groups (1) Curative group (CG) , treated with brachytherapy alone: patients who have a small tumor without extrabronchial extension. Surgery or external irradiation (RT) were not possible, because of chronic respiratory failure or previous treatment (previous RT = 87%). (2) Brachytherapy as a local boost after RT (EBRT + BT) : initial treatment of lung cancer patients, stages I–IIIB, who have a large endobronchial component at diagnosis. (3) Palliative group (PG) : patients with a large obstructing tumor or with metastases. Population 148 pts have been treated. CG = 69; EBRT + BT = 48; PG = 31. Mean endobronchial tumor length : CG = 2 cm; EBRT + BT = 2.6cm;PG = 4.5cm. Protocol: CG; = 6 fractions of 7 Gy in 1 month; EBRT + BT : 2 fractions of 5 or 7 Gy, 15 days after external irradiation; PG ; 2 to 6 fractions of 7 Gy. Results PG: Objective endoscopic response: 71%; Symptomatic improvement: 62% CG ; 78% of complete histologic disappearance of the tumor (CHR). 33%of the pts relapse in the treated areas. EBRT + BT : 83% of CHR. Survival 3-year survivals were: PG : 0%; CG : 51%; EBRT + BT : 69%. Most of the pts in the CG died of local disease. Conclusion It seems to exist a subgroup of patients, with a low metastatic potential, which can be cured by brachytherapy alone.