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Objective: We wished to evaluate the influence of postoperative radiotherapy on the incidence of tumour regrowth in non-secreting pituitary adenomas., Methods: The cases of 57 patients with clinically non-secreting pituitary adenomas were retained for a retrospective study of long-term disease-free survival out of a series of 66 patients treated between 1970 and 1988. Thirty-three patients were treated by surgery only (Group A), and twenty-four by surgery followed by external radiotherapy (Group B). Disease-free survival curves were calculated according to the Kaplan-Meyer method and compared by the Logrank test. The impact of some supposed prognostic parameters--such as tumoural volume, macroscopic features of invasiveness and quality of surgical resection--on the disease-free survival was analyzed according to the Logrank adjusted test., Results: The mean follow-up duration was 7.1 +/- 6.2 years, and eleven patients relapsed: nine in group A (27.0%) and two in group B (8.3%), with respective free intervals of 6.1 +/- 5.0 years and 9.6 +/- 2.4 years. Statistical analysis of the disease-free survival curves confirmed that this difference was significant (p < 0.01). Further analysis of putative risk factors (the importance of extrasellar extension and the estimated quality of surgical resection) was attempted, but it did not reach statistical significance., Conclusions: Radiotherapy is effective in preventing post-operative regrowth of non-secreting pituitary adenomas. Whether it should be systematically proposed or reserved to selected cases remains to be evaluated.

The efficacy of elective radiotherapy in N0 cancer of the oropharynx, hypopharynx and supraglottic larynx was assessed retrospectively in a large series of head and neck cancer patients treated at the Institut Curie between 1958 and 1976. Despite a significant incidence of false-negative cases accompanied by extra-capsular tumor spread, radiation tissue doses of 4500-5500 cGy were highly successful in preventing nodal disease in clinically negative necks. Isolated node failure occurred in only 2% of 611 cases of oropharyngeal and pharyngolaryngeal cancer from a total group of 1646 patients and 2% of 237 N0 cases of supraglottic vestibular cancer taken from a series of 340 patients. The impact of neck status on survival and disease-free survival is discussed. Present findings show that elective irradiation of the neck is easily integrated into the radiation management of primary pharyngeal and supraglottic laryngeal cancers and results in no additional morbidity to patients so treated.

In a previous analysis of node failures in 1251 consecutive patients with node positive oropharyngeal and pharyngolaryngeal squamous cell carcinomas treated by external radiotherapy alone at the Institut Curie, the main reasons for patient exclusion were node recurrence associated with primary failure (N+T failures) and doses less than 55 Gy. These exclusions reduced the number of node failures from 399/1251 (32%) to 77/798 (10%). Multivariate analysis of node recurrence indicated that node size and fixity, treatment duration, and T stage of primary were significant (higher probability of isolated node failure for the T1-T2 primaries). In the present analysis, it is noted that 60% of the N+T failures were observed less than 1 month after the completion of the irradiation and, therefore, were not likely the result of reseeding from the primary tumor. When all 1251 patients were included in the analysis, the probability of nodal failure increased for larger nodes, T4 primaries, lower nodal doses, presence of contralateral node metastases, and nodal fixation to the surrounding structures. No influence of the primary site was found. Treatment duration was closely associated with total dose to the nodes. The best description of the data was obtained with a model including total dose and not treatment time. However, as in the previous analysis, the exclusion of low-dose (less than 55 Gy) treatments resulted in the loss of a significant dose-control relationship. We conclude that the majority of node failures is unlikely to result from reseeding from the primary tumor, and therefore should not be excluded from local-control analyses. From a more radiobiological point of view, the exclusion of palliative treatments is questionable when studying the effect of dose on local control.

Fifty-seven patients with optic gliomas, treated by megavoltage radiotherapy between May 1970 and March 1986, are retrospectively analyzed. The mean follow-up was 7.5 years (2.5-16.5). At presentation, 46% were under 10 years old, 40% had neurofibromatosis, and 51% had neurological and/or endocrinological signs. Twenty-one tumors (37%) were confined to the optic chiasm, and 36 tumors (63%) extended to the hypothalamus, the posterior optic tract, or the adjacent brain. Two among the 16 biopsy-proven tumors were high grade gliomas. Delivered tumor doses were 40 to 60 Gy in 5 to 7 weeks. Forty-nine patients were alive (five with tumor evolution) and eight had died (five from the tumor, one from cerebrovascular complication, two from intercurrent disease). Overall actuarial survival was 83.5% at 5 and 10 years. Control of the disease in 53 evaluables patients was: complete response in 8 (15%), partial response in 25 (46%), and no progression in 12 (22%). Progressive disease was observed in three patients and signs evocative of recurrence in five others. Stabilization of visual impairment or improvement of vision was recorded in 93% of patients who were evaluable. A critical review of the literature is presented and complications discussed. Radiotherapy seems thus effective in chiasmal gliomas and must be delivered in cases of rapidly developing symptoms visual, neurological, or endocrine.

Between 1960 and 1980, 166 patients with squamous cell carcinoma of the base of the tongue were treated with primary irradiation at the Curie Institute (Paris, France). Distribution according to the TNM system 1978 International Union Against Cancer (UICC) was the following: 22 T1 lesions, 47 T2 lesions, 64 T3 lesions, and 33 T4 lesions. Regional nodes were not palpable in 50 cases, 35 had N1 nodes, 12 had N2 nodes, and 69 had N3 nodes. All patients received external beam radiation. The 2-year, 3-year, and 5-year overall survival rates for all patients were, respectively, 45%, 37%, and 27%. Local control was significantly related to the initial status of the primary, to the tumor regression at the end of the radiation therapy, and to the histologic differentiation. The 2-year local control was 96% for T1 lesions, 57% for T2 lesions, 45% for T3 lesions, and 23% for T4 lesions. Local control was 70% if the tumor regression was complete at the end of the treatment and 27% if the tumor regression was partial. No significant differences were found in primary local control with respect to degree of infiltration, age, and dose of radiation therapy over a dose of 60 Gy in 6 weeks. The 3-year regional control was 86% for N0, 78% for N1, and 60% for N2 and N3. Among the tumor characteristics analyzed, the most useful ones for predicting local control and survival were clinical tumor staging parameters and tumor radiation-induced regression. A new therapeutic approach based on the evaluation of the tumor regression at 50/55 Gy is under discussion.

Recently, Bataini et al. reported that overall time was the major treatment-related determinant of local control in 465 squamous carcinomas of the tonsillar region. They did not, however, quantify the relationship or relate it to the doubling time of tumorigenic cells, except qualitatively. This note reports an attempt at that quantification.

Two thousand thirteen patients with squamous cell carcinoma of oropharynx and pharyngolarynx were reviewed with regard to neck disease presentation and disease-free survival after radical radiotherapy. All patients were staged according to both the AJCC 1976 and the UICC 1978 classifications. Causes of failure, disease-free survival, and complication rates were assessed. Sixty percent had a clinically positive neck. The 3-year disease-free survival rates were 58%, 44%, 38%, and 25% for AJCC N0, N1, N2, and N3 cases, respectively. Corresponding UICC figures were 58%, 46%, 26%, and 29%. Analyzed parameters were nodal stage, size, site and fixity, and location of primary. Complications attributed to neck disease did not exceed 3%. A critical appraisal of the nodal staging systems is derived from these sets of data.

The prognostic significance of tumor regression following radiotherapy was evaluated in 1,897 patients with oro- and pharyngolaryngeal cancer. Complete tumor regression occurred in 62% and 80% at the end of treatment and 2 months later, respectively. Complete regression was significantly higher for early tumors than for advanced stages and for exophytic lesions compared to deeply infiltrative cancers. Depending on tumor location, 75% to 90% of T1, T2 stages and 50% to 80% of more advanced tumors were locally controlled in patients who experienced complete tumor regression at 2 months. The local failure rate was at least 80% for those who did not have complete regression. The local failure rate for the incomplete responder was the same for early and advanced tumors. Complete tumor clearance following radiotherapy is a reliable indicator of permanent local control. Tumor regression after a dose of 5,000 to 5,500 cGy should be used as a guide to select patients who could be treated by either radical irradiation or surgery.

Delayed cerebral radiation necrosis was discovered 13 years after irradiation of the skull for osteosarcoma. Conservative treatment with glucocorticoids is discussed.

In a 13-case series of epithelioma of the floor of the mouth given cobalt-therapy irrespective of the selected therapeutic protocol, the authors recorded 5 cases of osteoradionecrosis. In this study, they review both risk and prevention factors linked with radionecrosis at the localization site of this particular type of tumor. They also stress the importance of adapting the treatments, when introducing so-called néo-adjuvant systemic chemotherapy, the high efficacy rate of which is likely to reduce the risks of radionecrosis. This can be achieved either by eliminating completely or limiting the surgical step, or by bringing modifications to the post-operative radiation regimen.

At the Curie Institute, between 1958-1980, 166 patients were treated for squamous cell carcinoma of the base of the tongue, by external radiotherapy alone. The absolute survival was 45%, 39%, 26% at 2, 3, 5 years. 95% local and loco-regional failures arrived within the first two years; the nodal failures isolated were rare (4%). Unfavorable prognosis features are: the size of the tumor and the clinical radiation-induced regression of the primary. A new therapeutic approach is discussed: an additive curietherapy for some T1-T2 and a surgical excision (total glossectomy with or without neck dissection) for some T3-T4 of which the regression is unsatisfactory at 50-55 Gy are proposed.

Out of a consecutive series of 698 cases of squamous cell carcinomas of the tonsillar region treated by radical megavoltage radiotherapy, a determinate group of 465 cases remained eligible for a multivariate analysis of the pretreatment features of the disease and treatment-related parameters predictive of lasting control of the disease at the primary site. T-stage and initial site within the tonsillar region, were the significant pretreatment factors. Tumours arising from the glossopalatine sulcus which are characterized by involvement of the tongue, do significantly worse than those arising from other sites within the tonsillar region: i.e. the tonsil itself, posterior pillar and to a lesser extent the anterior pillar. As regards treatment-related parameters in the 465 cases which received tumour doses of at least 55 Gy, only the length of overall treatment time was found to be predictive. Combining both pretreatment and treatment variables, T-stage (p less than 0.0001), overall treatment time (p less than 0.0001) were by decreasing order of significance the predicting factors, followed by initial site (p = 0.006). When present, tumour extension to the anatomical structures anterior to the tonsillar region was also found to be significant (p = 0.05). Based on these factors, a multivariate model was constructed and tested by estimating the product-limit survival of the various categories of patients. Four groups are individualized with 3 years local control rates ranging from 90 to 21%. The predictive accuracy of the model was assessed by log-rank test significance levels. The model may help to select patients for whom conventional radical radiotherapy is inadequate, and combined modality or altered fractionation regimes should be tried particularly for advanced tumours of the glossopalatine sulcus, and any case with significant invasion of the oral cavity.

We reviewed a series of 1,666 patients with squamous cell carcinoma of the oropharynx and pharyngolarynx treated with definitive radiation therapy to determine whether or not radioresponsiveness of the metastatic neck nodes is a reliable indicator of their radiocurability. In a determined group of 708 patients with clinically positive neck nodes, only one third of the adenopathies (247/759) completely regressed at the completion of the treatment. At 6 months, only ten percent of the nodes remained palpable. Lymph node clearance rates and halving diameter times were tumor size-dependent. Node clearance rate was also influenced by the site of the primary lesion. The impact of various parameters, both intrinsic and extrinsic to the tumor behavior, is discussed. Neck control probability was significantly higher for complete responders. In this group, the ultimate node control was as good for adenopathies larger than 6 cm as for the smaller ones. Tumor control probability directly related to clearance rate following radiotherapy. Finally, therapeutic implications are derived for nodal dose adjustments and optimal applicability of radiosurgical combinations.

Radiation-induced cancers are fortunately a very rare complication of radiotherapy for cancers. Sagerman, however, reported 21 cases in a series of 243 patients with retinoblastomas, examined after a period of at least 5 years, and 6 cases were observed in a similar series of 112 children seen at the Curie Institute. This report describes 10 cases of irradiation-induced cancers of the maxillofacial region seen at the Curie Institute over a period of 30 years. The exceptional nature of this risk is such that it cannot represent a contra-indication to irradiation therapy of a malignant tumor, especially now that low-energy radiation has been abandoned, and with the modern therapeutic procedures available. The risks of cancer are greater, however, after irradiation of benign bone lesions and benign affections of the cervico-facial region. Treatment of these benign affections in children or young adults by low or reduced doses of conventional low-energy radiations should be forbidden, and the indication for treatment with radiations, which must be of high voltage, should be exceptional.

Improved techniques for inducing heat: ultrasound, microwaves, diathermy with different application modalities, capable of producing localized superficial or deep, regional or total body hyperthermia have been responsible for the multiplication of clinical trials. These studies have confirmed the tumoricidal effect of hyperthermia alone, or more especially when combined with radiotherapy, and the good tolerance of normal tissues to localized temperatures of 42 to 43.5 degrees C even in previously irradiated cases. Localized heating does not seem to increase the incidence of metastasis. Enhancement ratios and therapeutic gain with respect to normal tissues are not yet well documented. Many problems, including the heterogenicity of tissues to be heated, difficulties with temperature monitoring, and selection of appropriate sequential scheduling of radiation and hyperthermia remain unsolved and further investigations are required.

Between 1962 and 1980, 21 patients with anal margin carcinoma were treated with exclusive radiotherapy. They were divided into 4 T1, 7 T2, 8 T3 and 2 T4 cases; only 3 cases presented with an N1 lymph node involvement (1 T2 and 2 T3). The tumor dose was 65 Gy in 22 fractions and 55 days; the inguinal dose was 50 Gy in 15 sessions and 50 days for prophylactic irradiation performed in 9/18 N0 patients, and 65 Gy with a limited 15 Gy boost for the 3 N1 cases. The results are: for T1, 4 patients alive and well out of 4; for T2, 3 out of 7; for T3, 2 out of 8; for T4, 2 out of 2. The overall survival was 11 out of 21 after 5 years. Severe complications occurred in 2 patients out of 21. Sphincter preservation was obtained in 9 patients out of 10 cured cases.

Radiation-induced cancer, although fortunately a rare complication of radiotherapy, is nonetheless observed occasionally even after megavoltage radiation has been used. Over a 22-year period at the Curie Institute, four patients were found to have malignant neoplasms within the fields of megavoltage treatment given for various cancers of the head and neck region. Three of the neoplasms were sarcomas, two osteogenic and one fibrosarcoma, and the other tumor was a sarcomatoid epithelioma. The latent period ranged from 3 1/2-15 years. Although the evidence is strong that the neoplasms were causally related to the precedent irradiation, it is acknowledged that rare examples of the "double primary" phenomenon exist, even separated by five or more years, and that only one such instance would induce a large error in the estimated frequency of postirradiation neoplasms. Because clinical estimates after megavoltage irradiation are usually compounded by an association with a relatively high total absorbed dose, the issue of the incidence of postirradiation neoplasms as a function of the type of external beam (orthovoltage vs. megavoltage) may require resolution by experimental means. Another rare sequela of radiotherapy is injury to a peripheral nerve. One of the four patients with a second neoplasm after radiation also developed left hypoglossal nerve palsy 2 1/2 years post-therapy, and left optic nerve atrophy seven years postradiation treatment of a squamous cell carcinoma of the ethmoid and maxillary sinuses. The 51-year-old patient had received a tumor dose of 6800 rads (2043 rets).

The authors present the therapeutical results of two clinical and histological homogeneous series of malignant gliomas. The first group includes 46 patients operated upon and treated successively by chemotherapy associating VM26 and CCNU, a conventional delayed radiotherapy 6 months after surgery and again chemotherapy. In this group, the mean survival is 17 months and 46% of patients were surviving at 18 months. The second group includes 28 patients operated upon and treated with the same associated chemotherapy without radiation therapy. The mean survival was 11 months and 24% of patients were surviving at 18 months. The comparison of results shows that after surgery, the association of a chemotherapy and delayed radiotherapy is more efficient than chemotherapy alone. However, the systematic study of nervous system tolerance to irradiation post-chemotherapy suggests that, in some cases, the chemotherapy is able of increasing the pathogenic effect of irradiation on the brain.

The results obtained in this series of 120 patients with brain tumors, excepting hemispheric gliomas, appear particularly comforting. Radiosensitiveness of medulloblastomas, pinealomas and to some extent of ependymomas, was of course known. On the contrary, the radio-sensitiveness of some astrocytary processes, or supposed astrocytomas, well or moderately differentiated (gliomas of the IIIrd. ventricle, opto-chiasmatic gliomas, gliomas of the brain stem) appears to have been appreciable and it has been possible to obtain numerous stabilizations equivalent to cures. An histologic chek-up prior to roentgentherapy appears to authors as strictly necessary and might be easily enough obtained thanks to the stereotaxic procedures. Authors are not of mind that the present series will be burdened with radio-necrotic like complications. They think that the tumoral doses might be increased of 5 p. 100 and even of 10 p. 100, while maintaining the same protraction and a fractioning of the same order: treatments of 5 to seven weeks consisting in 5 to 6 sessions per week). It is presently too soon for valuing the efficiency of an adjuvant chemotherapy.

Research was carried out into a group of 11 patients with tumours of the olfactory placode or aesthesioneuromas observed and treated by the authors (10 of them unpublished cases). The authors recall the histological characteristics which, theoretically, distinguish aesthesioneuroepithelioma from aesthesioneurocytoma and aesthesioneuroblastoma and the risk of mistaken interpretation due to confusion with other types of tumour. The following conclusions emerged from this research : 1) Aesthesioneuroma is indisputably a radiosensitive tumour as has been proved by the long-term cures obtained either by irradiation alone or by irradiation after incomplete surgery. 2) However it is exceptional for diagnosis to be made merely by intranasal biopsy. In all doubtful cases, surgical investigation is necessary. This requires a broad para-latero nasal approach route which is the only one affording accurate anatomical localisation of the lesions and complete ablation of the tumour including, where necessary, removal of the lamina cribrosa.

Twenty-five patients with 35 cranial nerve palsies were seen at the Fondation Curie during follow-up after radical radiotherapy for head and neck tumors. The twelfth nerve was involved in 19 cases, the tenth in nine, and the eleventh in five; the fifth and second nerves were involved once each and in the same patient. The twelfth nerve was involved alone in 16 patients and the tenth nerve alone in three, with multiple nerves involved in the remaining six patients. The palsy was noted from 12 to 145 months after diagnosis of the tumor. The latency period could be correlated with dose so that the least square fit equation representing NSD vs delay in NSD = 2598 - Delay (in months) X 4.6, with a correlation coefficient of -0.58. The distinction between tumor recurrence and radiation-induced nerve palsy is critical. It can often be inferred from the latency period but must be confirmed by observation over a period of time.

Forty-six patients with gliomas were introduced after surgery into a therapeutic programme of six cycles of combination chemotherapy with VM26 and CCNU, followed by delayed irradiation six months after surgery with an average dose of 5,800 rads. After irradiation the same preradiation chemotherapy was readministered for an average of four cycles. The results were compared to those from another group of 28 patients treated only by the same chemotherapy (CRC and C groups sucessively). Twelve patients (26%) died before irradiation in the CRC group, six patients (13%) had recurrences at the time of irradiation, and 28 patients (61%) had no clinical or radiological signs of recurrence at the time of irradiation. For the total of treated patients the median survival after surgery was 17 months, and 46% of the patients were surviving at 18 months. The percentage of survivors at 18 months was significantly more elevated in the group treated by combination chemotherapy and delayed irradiation than in a control group treated by the same combination chemotherapy alone. This result suggests that in approximately 50% of cases combination chemotherapy after surgery, and delayed irradiation six months after surgery, cumulated their effects on survival time.

A series of 138 mucinous breast carcinomas was treated at the Institut Curie from 1970 to 1980: 107 were diagnosed as "pure" mucinous carcinoma and 31 as "mixed" mucinous carcinomas. Fifty per cent of the cases were stage T2 and 78% N0-N1a. Treatment methods were radical mastectomy in 113 cases (82%) with pre-operative irradiation for 37 patients and post-operative irradiation for 14 patients. A conservative treatment was used for 25 patients, consisting either of lumpectomy followed by radiotherapy (in 15 cases) or radiotherapy alone (in 10 cases). The five-year actuarial survival rate was 81% for the "pure" group and 87% for the "mixed" group; it was 70 and 75%, respectively, at ten years follow-up. In this series, survival was not influenced by the type of treatment. The efficacy of radiotherapy was evaluated from the local recurrence rate: only four local failures among the 25 conservative treatments were noted. Our conclusion is that radiotherapy, with or without lumpectomy, is efficient in mucinous breast carcinoma and could be useful in selected cases.

34 patients operated on for malignant gliomas were successively treated by combination chemotherapy with VM26 and CCNU and conventional radiation therapy with an average dosage of 5,800 Rads, six months after surgery. The general and haematological tolerance of delayed irradiation after chemotherapy was satisfactory. Twelve patients developed neurological complications during or after irradiation. The complications were early in 10 cases, and delayed in 2. They were probably due to tumour growth in five cases, and secondary to irradiation in seven. In four of the seven cases the preradiation chemotherapy seemed to potentiate the radiation effect on the central nervous system.

Eight patients with lacrimal sac epitheliomas are reported and the published literature reviewed. Clinical signs of these very particular type of tumor are described, as well as their method of extension to the upper facial region which has now been perfectly documented by computed tomography images. Papillomatous forms are relatively frequent, progression of the tumors is slow, and the prognosis for recurrences is fairly good if extensive surgery has been applied.

One hundred thirty-eight patients, who were followed for a minimum of 5 years, had either surgery and postoperative radiotherapy (48 patients) or radiotherapy only (90 patients) for metastatic epidermoid carcinoma in cervical nodes from an unknown head and neck primary. All received radiotherapy to the presumed occult sites. Forty-five percent presented with a single unilateral adenopathy. Those who were initially operable had a neck recurrence rate of 17% and a survival rate of 53%. Forty-three percent of initially inoperable patients recurred and only 25% survived. Patients with adenopathy which completely regressed or became resectable after irradiation had an 80% locoregional control. Only 4% developed an overt cancer at an occult site within 5 years.

67 patients with tumors 3 cm or less and with negative axilla, who had lumpectomy and radiotherapy, and 122 patients with larger tumors or clinically positive axilla, who had radical radiotherapy without prior lumpectomy, were evaluated at five years to determine the optimum dose for local control. 7000 rad in seven to eight weeks controlled 85% of lumpectomy cases, whereas 8000 rad in 81/2 weeks were required to control two-thirds of cases treated by radical irradiation alone. Subclinical (N0, N1a) and clinical disease (N1b) in the axilla was controlled, in a very high percentage, when 6000 and 7000 rad were delivered, respectively. Dose response curves were obtained for clinical disease in the breast and axilla. No such response was elicited for subclinical disease. Undifferentiated cancers had higher recurrence rates than well differentiated tumors. Radiation fibrosis in lumpectomy cases was insignificant, whereas 10% of radically irradiated patients had fibrosis of the breast.

Seventy-seven patients with inflammatory breast carcinoma were included in a randomized trial between march 1977 and september 1979. All patients were treated with the same association of chemotherapy and radiation therapy. Chemotherapy included adriamycin on day 1 (45 mg/m2), vincristine on day 2(1,2 mg/m2), cyclophosphamide on days 3, 4 and 5 (400 mg/m2/day) and 5 fluoro-uracil on days 3, 4, and 5 (500 mg/m2/day). Each course of chemotherapy was repeated every 28 days for one year. Patients were then given a maintenance course of chemotherapy for one year. Radiation therapy with CO60 was applied after 4 courses of intensive chemotherapy. The dose distributed was 70 Gy over seven weeks. During radiation therapy, chemotherapy was administered according the same scheme, but adriamycin was excluded. All the patients were randomly distributed into two groups before treatment: group I patients received chemotherapy and radiation therapy alone; group II patients received chemotherapy and radiation therapy plus living BCG vaccinations. After chemotherapy, inflammatory manifestations disappeared in 51% of cases. The mean of disease-free interval was 26 months and the overall survival mean 34 months. No difference in favor of the BCG treated group was noted. Lymph node involvement, age, hormonal status, response to tuberculin, and disappearance of inflammatory signs after 4 months of chemotherapy are of insignificant prognostic value.

Out of a series of 1666 consecutive patients with squamous cell carcinoma of oropharynx and pharyngolarynx, 1646 were evaluable at a 3-year interval following radical radiation therapy. The actuarial 3-year nodal control rate using the AJC classification was: N0 98%, N1 90%, N2 88%, N3 71% when the primary was controlled. The regional outcome is influenced by clinical features such as nodal size, multiplicity and fixity. Cervical recurrence frequency is higher for pharyngolaryngeal carcinoma than for oropharyngeal cancer. The impact of the treatment planning on regional control is discussed. Due to the of concomitant boosting of nodes, cervical metastases were treated according to a type of accelerated fractionation schedule with weekly doses of 12-15 Gy for a total of 70-85 Gy in 75% of the cases. Clear-cut dose control relationships are demonstrated for nodes larger than 3 cm in diameter. Overboosting residual cervical disease fails to yield a better nodal control. Comparative analysis is established between results obtained with this high dose per fraction radiotherapy schedule, conventional regimens of irradiation and other new approaches, combining chemical and physical agents. Therapeutic implications are also derived to define adequate field coverage.

This is an evaluation of definitive conventional megavoltage radiotherapy in a consecutive series of 35 patients presenting malignant epithelial tumours of the parotid gland. In this series, the 5-year actuarial locoregional control rate was 41% with a 5-year crude survival rate of 36%. The results are analyzed according to tumour presentation and tumour doses. Six of 15 patients with tumours larger than 6 cm have had a lasting locoregional control. During the same period 43 other patients received radiotherapy as a post-operative modality. Results obtained in this group confirm the previously published data. While recent studies tend to demonstrate the specific efficacy of high LET radiation in the management of locally advanced salivary gland tumours, radical conventional radiotherapy can still be employed with a curative intent when neutron facilities are not available.

Eight cases of glomus jugulare tumours were irradiated with megavoltage from 1964 through 1978. All had extensive bone destruction of the base of skull 5 000 to 6 000 rads in 7 of the cases. Regression of functional signs was constant whereas regression of palsies was rare and recalcification of bone lesions exceptional. All patients are living with apparent control of disease for periods of 16 to ç years. Accurate technique is indispensible to prevent radiation myelitis. For the extensive jugulare tumours results of radiotherapy compare very favorably with those of extensive surgery.

Twenty-six adult patients with the pathologic diagnosis of desmoid tumor were treated between 1964 and 1983 at the Institut Curie in Paris with megavoltage irradiation. Twenty of these patients (76 percent) had extraabdominal tumors. Definitive surgical resection was performed on nine patients (one received preoperative radiotherapy). At last follow-up 1 1/2 to 10 years after treatment, all of the patients had no evidence of disease. Seven of the nine had follow-up examinations from 5 to 10 years after treatment. Seven patients had postoperative radiotherapy with doses from 4,700 to 6,500 rads (47 to 65 Gy) for either microscopic (three patients) or gross (four patients) residual disease. All but one patient had no evidence of disease from 2 to 8 years after treatment. Nine patients had radiotherapy for recurrent inoperable tumors and six had no evidence of disease from 3 to 20 years after treatment. Recurrences developed in three patients; outside the treatment portal in one, and the other two had received less than 5,000 rads (50 Gy). Clinical regression of tumors after treatment was slow, with complete regression taking up to 2 years. Postoperative radiotherapy with doses of at least 5,000 to 6,000 rads (50 to 60 Gy) was effective in achieving local control of inoperable or incompletely resected tumors, thus the need for repeated resections was avoided. Computerized tomography has greatly improved the assessment of tumor extension and should be used routinely before either operation or radiotherapy to obtain adequate margins and minimize the chance of missing disease.

Treatment results of epilaryngeal cancer are rarely individualized in the world literature. For this purpose, we have reviewed the records of 167 patients with squamous cell carcinoma of the lateral epilarynx who received radical radiotherapy at the Institut Curie on a megavoltage unit, between 1959-1975. Two-thirds of the lesions were located at the junction of the ary- and pharyngo-epiglottic folds and lateral border of the epiglottis. Forty-four percent of patients had advanced primary lesions (T3, T4) and over 50% had palpable neck nodes at the time of presentation. The absolute survival for the entire patient population at 3 and 5 years was 44% and 32%. Local control for T1 and T2 tumors at 3 years was about 80%. Survival at 5 years for the N0 Stage patient was 40%, whereas it was about 20% for those with clinically palpable nodes. Patients with exophytic tumors and lesions which regressed completely within 8 weeks following irradiation had a significantly better 3-year survival and local control than those with nonexophytic tumors and with tumors which had incompletely regressed after irradiation. Radiotherapy remains the treatment of choice for the small tumors (T1, T2) but the association of radical surgery with pre- or postoperative radiotherapy should be considered for advanced disease.

Out of a series of 235 patients presenting with tumours of the soft palate at the Institut Curie, between 1958 and 1980, 146 cases were analysed to evaluate the results of radical radiation therapy. Seventy patients (48%) had advanced T3-T4 disease and 40 patients (27%) had clinically involved metastatic nodes. All patients had a minimum follow-up of 5 years. In 103 cases, megavoltage X-ray therapy was employed. For 43 patients, presenting with small or moderately advanced tumours, a combination of megavoltage and intra-oral orthovoltage X-rays was used. The local control rate at 3 years was 92% for T1, 70% for T2, 58% for T3 and 49% for T4 lesions. Nodal failure was seen in 19 patients. In 9 of these, it was not associated with failure at the primary site, 7 out of 9 occurring marginally or outside the treatment portals. Complications were observed in 16 patients, 7 requiring surgery. The crude 3 and 5 year survival rate was 52 and 40%, respectively, and the disease-free survival 59 and 53%.

Out of a series of 2040 patients referred to the Institut Curie with squamous cell carcinoma of oropharynx and pharyngolarynx, 1666 cases were evaluated on admission regarding the characteristic metastases patterns to their cervical lymph nodes. Incidence and topographic distribution of lymph nodes are correlated with the anatomic sites of primary lesions. Biological virulence of these tumors is emphasized since the overall incidence of positive neck nodes attains 63% (1048/1666) and advanced disease, stage IV in the UICC classification, 61%. Cervical status is also related to several characteristics of the primary: clinical staging and variety, and histopathological differentiation. Ipsilateral cervical involvement is characterized by the high incidence of metastases in the jugular chain for the whole series, in the submaxillary group for oropharyngeal carcinomas and in the spinal accessory chain for cancer of the pharyngolarynx (pyriform sinus and lateral epilarynx). Preliminary therapeutic implications are derived from this nodal distribution. Comparisons are established between the 1978 UICC and 1976 AJC classifications, showing a good correlation despite multiple differences in staging criteria. It is shown that assessment combining both the multiplicity and the volume of cervical metastases allows to evaluate more accurately the aggressiveness of the primary.