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From April 1971 to October 1984, 71 patients with T1 or T2 tumors of the faucial arch were treated according to the following protocol: Telecobalt therapy to the primary site and to the neck nodes to a dose of 45 Gy. Brachytherapy to the primary site to a dose of 25 to 30 Gy using iridium 192. For node positive patients, boost dose to involved neck nodes with electrons, or radical neck dissection. Seven patients with T1N0 tumors were treated exclusively by 60 Gy iridium implantation. The crude disease free survival is 66% for the group of patients with tumors of the tonsillar region and 41% for those with tumors of the soft palate or uvula. Local control of tonsillar tumors was 98% while that of tumors of the soft palate was 85%. Regional control was 98% for the N0 group and 87% for the N1-3 group. Five cases of soft tissue ulceration were observed, all of which healed spontaneously within a few months. Less salivary impairment was seen than after treatment by external irradiation alone. While these promising results have encouraged the use of this protocol, the introduction of the plastic tube technique has expanded the indications to include almost all T1 and T2 tumors of the faucial arch without obvious extension to the base of tongue or retromolar trigone.

Before loco regional treatment for head and neck cancer forty eight patients received one or the other of the following combined chemotherapy regimens: Regimen A (28 patients): high dosage methotrexate, bleomycin, cis-platin; regimen B (20 patients): common dosage methotrexate, bleomycin, hydroxyurea, vincristin. The effectiveness of regimen A seemed better than that of regimen B (46% responses versus 20%). This assessment must be accepted with caution, since, although the organization of treatment was strictly similar in the two groups, the study was not randomized, and there were noticeable differences between the two groups. Regimen B was associated with no toxicity. Regimen A was responsible for two fatalities. These two cases were linked to high dosage methotrexate. However, a combined chemotherapy regimen of type A with the high dosage methotrexate replaced by intermediate dosage methotrexate, seems feasible to us. Loco regional treatment was not impaired by initial chemotherapy with either regimen.

Between May 1971 and March 1982, 73 patients with either recurrent or subsequent squamous cell carcinomas arising in a previously irradiated oropharynx were treated using iridium 192 wires. Although local control was achieved in 72% of these patients, only 10 remained alive at 5 years (14%). Local control was best for tonsillar arch lesions (96%), while base of tongue and glosso-tonsillar sulcus tumors were controlled in only 60%. One of the two patients with a posterior pharyngeal wall lesion is alive and well at 5 years, while the other died of an unknown cause at 20 months. Salvage implantation produced soft tissue necrosis in 36% of base of tongue implants, but only 18% of those involving the tonsillar arch. Although one necrosis was fatal, the others were successfully managed medically. Since these results compare favorably with those of previously published series, we recommend re-irradiation with iridium 192 for recurrent or new malignancies arising in a previously irradiated oropharynx. For tonsillar arch lesions, brachytherapy is the treatment of choice while in the base of tongue, it is reasonable option.

From 1970 to 1979, a group of 50 patients was treated for squamous cell carcinoma of the penis by interstitial irradiation using an afterloading technique and iridium 192 wires. The group included 9 patients with T1 tumors, 27 with T2 tumors, and 14 with T3 tumors. Forty-five patients presented with no metastatic inguinal nodes (N0), 3 patients with N1 nodes, and 2 patients had N3 nodes. After treatment, 11 patients (1 T1, 6 T2 and 4T3) developed local recurrences; 10 of these 11 patients underwent penile amputation which controlled the tumor in 7 of the patients. One patient refused amputation. Three patients developed post-therapeutic necrosis which necessitated partial amputation in 2 cases. Eight patients developed post-therapeutic urethral stenosis, which required surgical treatment in three of the cases. Overall, at their last follow-up examinations, 74% of the patients were free of disease with conservation of penile morphology and function. Most patients without metastatic nodes (37/45) at diagnosis did not receive prophylatic treatment of the groin. Two of these patients developed delayed metastatic nodes; one was successfully salvaged. All 5 patients presenting with metastatic nodes at diagnosis died, four with uncontrolled regional disease. Twenty-one percent of the patients died of their disease. We advocate interstitial irradiation using iridium 192 wires for the treatment of non-infiltrating or moderately infiltrating squamous cell carcinoma of the penis in which the largest dimension does not exceed 4 cm. Pre-implant circumcision and regular long-term follow-up are necessary. More extensive tumors are better managed surgically. When regular follow-up can be assured, it is reasonable to forgo prophylactic treatment of the inguinal nodes in patients presenting without groin metastasis.

From 1971 to 1979, 55 patients were treated for bladder cancer at the Henri-Mondor Hospital using a treatment protocol combining low dose pre-operative external beam radiation followed by iliac node dissection, limited partial cystectomy (or sometimes for T1 tumors, a trans-urethral resection) and curietherapy with iridium 192. The 5 year disease free survival was 37/55 (67%). The rate of local recurrences plus second tumors within the bladder was 16% (9/55). These results are compared with other conservative modalities of treatment of bladder cancer.

At the conclusion of our recently published article in this Journal on low dose rate irradiation in moderately extensive cancers of the oropharynx, we updated our results in May 1986. Here we report on an expanded group of 65 patients with a 2 year minimum follow-up; 32 patients were treated by low dose rate irradiation and 33 by conventional fractionation. Forty-four percent (14/32) low dose irradiation patients survived with NED vs 8/33 (24%) conventional fractionation patients. The highly significant differences in the level of local recurrences between patients treated by low dose rate irradiation, 5/32 (16%), compared with conventional fractionation, 20/33 (61%), highlights the enhanced efficacy of the low dose rate irradiation technique in the local cure of cancers of the oropharynx. This superior local control however is achieved at the cost of a number of necrosis, 5/32 (16%).

We report the comparative results for local tumor control between two groups of patients treated by radiotherapy fractionated in a conventional manner at normal high dose rate (29 patients with 2 years minimum follow-up and 24 patients with 3 years minimum follow-up) and by low dose rate radiotherapy (19 patients with 2 years minimum follow-up, 14 patients with 3 years minimum follow-up) with moderately extensive cancers of the oropharynx (T2b-T3a, 3-5 cm in diameter). At 2 and 3 years follow-up, the number of local recurrences in the patients treated with low dose rate radiotherapy is half (26 and 21%) that for those treated with conventionally fractionated radiation at normal high dose rates (52 and 54%). These results require more rigorous confirmation.

In preparation for the 18th meeting of the European Curietherapy Group, devoted to cancer of the lip, 2 363 cases of lip cancer from 23 European Hospitals were retrospectively analysed. After presentation of these results, several free communications, and a large interdisciplinary panel discussion, a consensus was reached for the management of the primary tumor and the regional lymph nodes. Interstitial implant with iridium 192 wires results in a local recurrence rate which does not excede 3,4%. This method may be considered the treatment of choice for T1 and T2 tumors and many T3 tumors. On the other hand surgery should be used for in situ tumors and very large deeply infiltrating tumors. As the 2% failure rate after routine prophylactic neck dissection does not significantly differ from the 3% failure rate when patients undergo neck dissection only if clinically positive neck nodes develop, patients with T1, T2 tumors and no palpable neck nodes, who can be expected to submit to regular follow-up examination, may be managed conservatively. Patients with clinically positive neck nodes should undergo a neck dissection followed by radiationtherapy.

These two meetings organised successively to discuss the conservative methods of treatment of breast cancer, made it possible to gather data on a substantial number of patients from an important number of European centers. It is encouraging to note that there is a general consensus among the various European centers concerning the basic principles of treatment and that long years of experience have led to the use of well defined technical protocols which are relatively similar from one center to another. Since serious complications have now become exceptional, we foresee that the conservative treatment of breast cancer will continue to evolve on a technical level as the indications for this approach continue to develop within the overall plan of patient care with the assurance that optimum results may be maintained. However, we must point out that the lack of a unified system of reporting irradiation doses in volumes corresponding to the possible and/or real extension of the tumor remains an obstacle in developing a truly unified attitude in the application of these techniques. Each center defines the radiation dose given by wide field techniques and the dose given by cone-down (boost) techniques in a relatively arbitrary way without true anatomic correlations. These correlations must be found and defined, so that a specified dose has a universal meaning. The role of the surgeon in the successful application of breast conserving techniques is far from negligible. Now that our colleagues who wield the scalpel have begun to gain confidence in the curative powers of irradiation, we may hope that a close collaboration between radiotherapist and surgeon will lead to the application of conservative techniques under optimal conditions in the breast, with the development of minimal tumorectomy and minimal curative cone-down dose; and in the axilla, with the development of axillary dissection limited to the lower border of the pectoralis minor and followed by radiation therapy only if more than two nodes show tumor involvement. However, it is important to point out that while it is possible to use radiation therapy alone to treat breast cancer and conserve the breast at all stages of the development of the disease, it is not possible to use conservative surgical techniques alone as a substitute for adequate irradiation. The development of protocols which routinely apply breast conserving methods in synonymous with the development and routine use of the best radiation therapy techniques. This article presents two separate and complementary studies of two different sets of data presented at two successive meetings.(ABSTRACT TRUNCATED AT 400 WORDS)

A series of 93 cases of endometrial adenocarcinoma stage I, of which 87 were treated by surgery in combination with pre- or postoperative irradiation, is analysed with respect to recurrence rate, survival and effect of preoperative irradiation on myometrial invasion. According to the authors, the treatment of choice remains a combination of surgery and radiation therapy in order to control the primary tumor and prevent vaginal recurrence. The authors recommend uterovaginal intracavitary irradiation followed by total abdominal hysterectomy and bilateral salpingo-oophorectomy with or without lymphadenectomy, and with adjunctive postoperative external irradiation reserved for the rare cases at high risk for locoregional failure (persistence of deep myometrial invasion, lymph node involvement).