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Resume Objectifs. – Analyse retrospective du traitement et identification des facteurs pronostiques des premieres rechutes locales isolees de sarcomes des tissus mous (tronc ou extremites). Patients et methodes. – Il s’agit d’une etude retrospective portant sur une cohorte de 83 patients adultes traites entre 1980 et 1999. La taille tumorale moyenne etait de 6 cm. La plupart des sarcomes etaient situes au niveau des extremites (n = 74), etaient profonds (n = 60), et proximaux (n = 53) ; trente etaient au contact des axes vasculonerveux. Il s’agissait principalement de 49 % d’histocytofibrosarcomes et de liposarcomes (20 %), de grade 2 (42 %) ou 3 (36 %), selon les criteres de la Federation nationale des centre de lutte contre le cancer (FNCLCC). Le traitement chirurgical de la rechute locale a consiste en une exerese large dans 32 cas, une resection marginale dans 46 cas, et cinq patients ont du avoir une amputation. Les tranches de section d’exerese ont ete classees R0 (n = 33), R1 (n = 47) et R2 (n = 3). Six patients ont recu une chimiotherapie neoadjuvante et sept patients une chimiotherapie adjuvante. Vingt-trois patients ont recu une irradiation externe postoperatoire de dose moyenne 55 Gy et 26 une curietherapie interstitielle de bas debit de dose par iridium 192 de dose moyenne de 45 Gy si delivree seule, et de 22 Gy si associee a la radiotherapie externe, 19 patients ayant ete re-irradies. Resultats. – Avec un suivi en mediane de 59 mois, 37 patients (45 %) ont souffert d’une rechute, uniquement locale pour 61 % d’entre eux. Dix-neuf patients ont eu secondairement des metastases a distance. En analyse multifactorielle, seule la profondeur tumorale (p = 0,05) et la reintervention chirurgicale lors de la prise en charge de la recidive apres une premiere chirurgie incomplete (p = 0,018) etaient des facteurs pronostiques de survie sans rechute, la radiotherapie (externe et/ou interstitielle) etant significative uniquement apres analyse unifactorielle (p = 0,05). Les taux de survie globale etaient respectivement de 73, 54 et 47 % a 3, 5 et 10 ans et decroissaient respectivement a 65, 35 et 32 % apres la seconde rechute locale. Apres analyse multifactorielle, la localisation tumorale au niveau du tronc (p = 0,0001) ou des membres inferieurs (p = 0,023), les tumeurs symptomatiques (p = 0,001), profondes (p = 0,01) et de haut grade (p = 0,01), ainsi que la survenue d’une seconde rechute locale (p = 0,004) etaient des facteurs pronostiques independants de survie globale. Conclusion. – L’analyse des resultats obtenus dans cette serie montre qu’une premiere rechute locale isolee de sarcome des tissus mous augmente considerablement le risque de developper une nouvelle rechute locale. La qualite du traitement local de la premiere rechute est capitale. Lorsqu’un traitement conservateur est envisageable, il doit autant que possible associer exerese chirurgicale et radiotherapie externe, la curietherapie etant prioritairement reservee aux rechutes en territoire irradie. Les efforts doivent etre poursuivis pour ameliorer la qualite de la prise en charge des tumeurs primitives au mieux realisee dans des centres experimentes.

Resume Objectif de l’etude. – Evaluer les resultats d’un traitement associant une chirurgie de premiere intention et une curietherapie vaginale postoperatoire dans des cancers du col uterin de petit volume, sans facteur de pronostic defavorable. Patientes et methodes. – Apres une colpohysterectomie elargie avec lymphadenectomie dans 27 cas, une colpohysterectomie dans un cas et une hysterectomie totale dans un cas, 29 patientes d’âge moyen 44 ans, atteintes de cancer classe IB1 pour 26 et IIA pour 3, et de diametre inferieur a 25 mm et en moyenne de 15 mm, ont eu une curietherapie vaginale postoperatoire prophylactique a bas debit de dose. Une transposition des ovaires a ete realisee dans le meme temps chirurgical chez 14 patientes d’âge moyen 35 ans, afin de preserver leur fonction ovarienne. Resultats. – Les taux de survie actuarielle specifique a cinq et dix ans etaient de 100 et de 90 %, avec un recul moyen de 75 mois. Une seule rechute pelvienne a ete observee. Le taux de complications de grade 1 etait de 7 %. Chez les femmes jeunes, le taux de conservation de la fonction ovarienne etait de 85 %. Conclusion. – Pour des cancers du col uterin de petit volume, un traitement associant une chirurgie et une curietherapie postoperatoire est une option therapeutique fiable. Les resultats sont identiques en termes de survie et de complications a ceux obtenus avec l’association standard de curietherapie uterovaginale et de chirurgie.

Resume Objectif. – L’objectif de cette etude prospective etait d’apprecier la faisabilite de l’evaluation des effets tardifs par l’echelle de LENT-SOMA apres traitement des sarcomes des tissus mous des membres et de comparer les resultats obtenus avec ceux de l’evaluation de la fonction par le score de Enneking. Patients et methodes. – Au moment de leur consultation de surveillance systematique, une cohorte de 32 patients consecutifs a ete evaluee en termes d’effets tardifs par l’echelle de LENT-SOMA et de resultat fonctionnel selon le score de Enneking. Le recul moyen etait de 65 mois apres la fin du traitement. Le traitement a consiste en une chirurgie conservatrice (dans tous les cas) suivie d’une radiotherapie (29 cas) et souvent associee a une chimiotherapie adjuvante (14 cas dont 12 chimioradiotherapies concomitantes). L’evaluation de la toxicite a ete retrospective pour les effets aigus et prospective pour les effets tardifs des tissus suivants : peau/tissus sous-cutanes, muscles/tissus mous et nerfs peripheriques. Resultats. – Selon le score de Enneking, le score global pour l’ensemble de la cohorte etait eleve (24 sur 30) malgre quatre patients avec un score zero pour le vecu du traitement. Selon l’echelle de LENT-SOMA, un taux faible de sequelles de grade 3 ou 4 a ete observe. La survenue de sequelles de haut grade et leur retentissement fonctionnel n’etaient pas lies a une chimiotherapie concomitante. Une complementarite a ete observee entre certains facteurs du score de Enneking et des criteres de l’echelle de LENT-SOMA, surtout pour les muscles/tissus mous. Conclusion. – La bonne qualite des resultats fonctionnels a ete confirmee par les deux scores utilises pour evaluer les effets tissulaires tardifs. L’application en routine de l’echelle de LENT-SOMA est plus longue que celle du score de Enneking (durees moyennes d’application respectivement de 13 et cinq minutes). L’echelle de LENT-SOMA a pour objectif une description detaillee de la toxicite tardive et des sequelles, alors que le score de Enneking donne une evaluation plus globale du resultat fonctionnel, incluant l’acceptation du traitement. L’evaluation de la toxicite tardive selon l’echelle de LENT-SOMA doit se poursuivre dans le cadre d’etudes prospectives, surtout en cas de chimioradiotherapie concomitante.

The goal of postoperative treatment in adult soft tissue sarcoma is local control, and in high-risk patients prevention of distant failures. Radiation therapy is essential after non-radical surgery. The role of adjuvant chemotherapy on improvement of overall survival remains to be evidenced; however, recent meta-analysis data have confirmed its impact on both local and metastatic evolution of the disease. Because for both radiotherapy and chemotherapy, delay of treatment may be crucial for efficacy following tumor excision, concomitant radiochemotherapy should be considered. Review of the literature as well as personal results showed the feasibility of postoperative radiochemotherapy in adult soft tissue sarcoma, even when the chemotherapeutic associations used included an anthracycline. Prospective study of radiochemotherapy should be performed in order to assess its real impact in terms of efficacy and toxicity.

Resume Objectif de l'etude Cette etude randomisee a pour objectif d'apprecier les avantages et les inconvenients d'une chimiotherapie neo-adjuvante dans des cancers du sein operables de plus de 3 cm de diametre. Patients et methodes Cet essai pragmatique randomise a ete conduit dans un seul centre (institut Bergonie, Bordeaux): 272 malades de moins de 70 ans ont ete incluses de janvier 1985 a avril 1989. Deux attitudes therapeutiques ont ete comparees: le groupe A (138 cas) recevait le traitement classique par mastectomie et curage axillaire avec chimiotherapie adjuvante en cas d'envahissement ganglionnaire (n = 82) ou de negativite du dosage de recepteurs hormonaux (n = 22); le groupe B (134 cas) recevait la meme chimiotherapie en induction avec un traitement locoregional adapte en fonction de la reponse obtenue. La dimension tumorale clinique initiale moyenne etait de 43 mm. Resultats La duree moyenne du suivi a ete de 124 mois. Dans le groupe B, 49 malades (36,5 %) se sont averees chimioresistantes d'emblee; 84 (62,6 %) ont ete chimiosensibles et ont beneficie d'un traitement conservateur. Dans ce dernier sous-groupe, la survenue d'une rechute locale a rendu necessaire une mastectomie seconde dans 19 cas (22,6 %). Les courbes de survie ne sont pas differentes dans les groupes A et B, bien que le nombre de rechutes locoregionales ait ete plus important dans le groupe B. A10 ans, la survie globale a ete de 60 % et la moitie des patientes vivantes du groupe B ont pu conserver leur sein. Conclusion La chimiotherapie d'induction a permis de realiser deux fois sur trois un traitement conservateur du sein, initialement juge impossible au prix d'un taux de rechute locoregionale plus important que ce que l'on observe apres mastectomie et chimiotherapie adjuvante.

Resume But de l'etude Il s'agissait d'etablir, grâce a une etude multicentrique, une nouvelle classification de la chirurgie des sarcomes des tissus mous (STM). Patients et methodes Des criteres purement descriptifs concernant l'exerese des STM ont ete elabores. La classification est fondee sur une synthese des termes chirurgicaux et de l'analyse anatomopathologique aboutissant a une definition de la resection (R): R0 = resection in sano, R1 = residu microscopique, R2 = residu macroscopique. La pertinence des criteres a ete evaluee par questionnaire retrospectivement sur des interventions anterieures, puis pendant 15 mois sur des interventions nouvelles. Resultats Cent soixante-seize comptes rendus operatoires etablis prospectivement par huit centres ont ete analyses. La majorite des chirurgiens a ete satisfaite de la nouvelle grille de definitions. L'ensemble l'a juge applicable aux interventions realisees. Dans 96 cas, la confrontation anatomoclinique a ete faite. Dans deux tiers des cas, il y avait concordance. Les cas de discordances etaient essentiellement notes dans les reprises d'exereses chirurgicales. Dans les 96 cas, la synthese de types de resection a ete jugee bonne et reproductible, permettant d'adapter le traitement. L'exploitation se poursuit. Des modifications de la grille tenant compte de propositions d'amelioration sont en cours. Conclusion Sous reserve de confirmation des premiers resultats favorables, la nouvelle classification de la qualite de la chirurgie des STM fondee sur des criteres objectifs et reproductibles devrait permettre d'harmoniser leur prise en charge et d'optimiser les traitements pluridisciplinaires.

Purpose To analyze the management and clinical outcome of patients treated for a first isolated local recurrence of soft tissue sarcomas (trunk or extremities) and to identify prognosis factors. Methods and material Between 1980 and 1999, 83 adult patients were included in the study. Mean age was 61 years. Mean tumor size was 6 cm. Most sarcomas were located in extremities ( n =74), were deep ( n =60), and proximal ( n =53); 30 involved nerves or vessels. Histologic subtypes were mainly grade 2 (42%) or 3 (36%) histiocytofibrosarcomas (49%) and liposarcomas (20%). Surgical treatment of recurrences consisted in wide excision (29 cases), marginal resection (43 cases), 5 patients requiring amputation. Final results were R0 ( n =33), R1 ( n =47) or R2 ( n =3) resection. Besides surgery, 6 patients received neo-adjuvant and 7 others adjuvant chemotherapy. Twenty three patients received post-operative external beam radiotherapy (EBRT) (mean dose 55 Gy) and 26 interstitial 192 Ir low dose rate brachytherapy (BCT) (mean dose 45 Gy for BCT alone, 22 Gy when associated with EBRT), 19 patients being re-irradiated. Results Mean follow up was 13 years. Thirty-seven (45%) patients relapsed, 62% of whom presenting an isolated local recurrence. Nineteen patients developed distant metastases. Multivariate analysis showed only tumor depth ( P =0.05) and re-resection for primary R1 resection ( P =0.018) being independent prognosis factors for tumor control, radiotherapy (EBRT and/or BCT) being significant in univariate analysis ( P =0.05). Overall survival rate was 73%, 54%, and 47% at, respectively, 3.5 and 10 years, and was 65%, 35% and 32% after a further local recurrence. Multivariate analysis showed trunk ( P =0.0001) or inferior extremity locations ( P =0.023), symptomatic ( P =0.001), high grade ( P =0.01), deep ( P =0.01) tumors, and the occurrence of a further local failure ( P =0.004) as unfavorable characteristics for overall survival. Conclusions A first isolated local recurrence of STS increases mainly the risk of a subsequent local relapse. Quality of local treatment is decisive. When a conservative treatment is feasible, it should combine surgical resection and radiotherapy, BCT being the best suited in previously irradiated patients. Efforts have to be pursued to increase quality of the treatment of primary tumors, at best performed in centers that have expertise in this field.

Evaluate the results of the treatment of small uterine cervix cancer with the association of surgery and postoperative vaginal brachytherapy, without unfavourable prognostic factors.After radical hysterectomy with lymphadenectomy, 29 women (mean age: 44 years) with carcinoma25 mm (26 stage IB1, 3 IIA, mean size: 15 mm) were treated by post-operative prophylactic vaginal brachytherapy using low dose rate. Ovarian transposition was performed at the surgical time in 14 young women (mean age 35 years).The actuarial specific survival rates at 5 and 10 years were 100% and 90% respectively, with a mean follow-up 75 months. Only one local recurrence was observed. The rate of grade 1 post-operative complication was 7%. The conservation rate of the ovarian function was 85% for young women.Treatment of small volume uterine cervix cancer using first surgery and post-operative vaginal brachytherapy is a reliable therapeutic option. The results in terms of specific survival and complications are the same with those after standard association of preoperative uterovaginal brachytherapy and surgery.

The aim of this prospective study is the feasibility of late effects assessment by LENT-SOMA scales after conservative treatment of soft tissue sarcomas of the extremities and a comparison with the functional evaluation by the Enneking score.During the systematic follow-up consultations, a series of 32 consecutive patients was evaluated in terms of late effects by LENT-SOMA scales and functional results by the Enneking score. The median time after treatment was 65 months. The treatment consisted of conservative surgery (all cases) followed by radiation therapy (29 cases), often combined with adjuvant therapy (12 concomitant radio-chemotherapy association cases out of 14). The assessment of the toxicity was retrospective for acute effects and prospective for the following late tissue damage: skin/subcutaneous tissues, muscles/soft tissues and peripheral nerves.According to the Enneking score, the global score for the overall series was high (24/30) despite four the scores zero for the psychological acceptance. According to LENT-SOMA scales, a low rate of severe sequellae (grade 3-4) was observed. The occurrence of high-grade sequellae and their functional consequences were not correlated with quality of exerese, dose of radiotherapy or use of concomitant chemotherapy. A complementarity was observed between certain factors of the Enneking score and some criteria of the LENT-SOMA scales, especially of muscles/soft tissues.The good quality of functional results was confirmed by the two mean scoring systems for late normal tissue damage. The routine use of LENT-SOMA seems to be more time consuming than the Enneking score (mean time of scoring: 13 versus five minutes). The LENT-SOMA scales are aimed at a detailed description of late toxicity and sequellae while the Enneking score provides a more global evaluation, including the psychological acceptance of treatment. The late effects assessment by the LENT-SOMA scales should be carried on in prospectives studies, especially in case of concomitant radio-chemotherapy.

The goal of postoperative treatment in adult soft tissue sarcoma is local control, and in high-risk patients prevention of distant failures. Radiation therapy is essential after non-radical surgery. The role of adjuvant chemotherapy on improvement of overall survival remains to be evidenced; however, recent meta-analysis data have confirmed its impact on both local and metastatic evolution of the disease. Because for both radiotherapy and chemotherapy, delay of treatment may be crucial for efficacy following tumor excision, concomitant radiochemotherapy should be considered. Review of the literature as well as personal results showed the feasibility of postoperative radiochemotherapy in adult soft tissue sarcoma, even when the chemotherapeutic associations used included an anthracycline. Prospective study of radiochemotherapy should be performed in order to assess its real impact in terms of efficacy and toxicity.

The aim of this randomised trial was to determine advantages and drawbacks of neo-adjuvant chemotherapy in patients with operable breast cancers3 cm.Two hundred and seventy-two women (age 70) with operable breast cancers larger than 3 cm (T2-3/N0-1/M0) were included in a randomised trial from January 1, 1985 to April 30, 1989. Patients in group A (n = 138) were treated by mastectomy and axillary node dissection. Adjuvant chemotherapy was indicated for 104 patients with axillary node involvement (n = 82) or negative oestrogen and progesterone receptors (EPR-) (n = 22). Patients in group B (n = 134) were treated by initial chemotherapy (identical as in group A) followed by locoregional treatment according to the response. Before treatment, the average of clinical tumoural diameter was 43 mm.The median follow-up was 124 months. In group B, 49 patients (36.5%) were resistant to chemotherapy; a conservative breast surgical treatment was performed in the other 84 patients sensitive to chemotherapy (62.6%). In this last subgroup, 19 (22.6%) needed a secondary mastectomy because of locoregional recurrence. Survival rates were not different in groups A and B, but loco-regional recurrences were frequent in group B. At 10 years, the overall survival rate was 60% and half of living patients in group B were free of cancer and with their breast.Neoadjuvant chemotherapy permitted in two-thirds of cases breast conservation treatment, initially considered to be impossible. Locoregional recurrences are more frequent than after mastectomy and adjuvant chemotherapy.

To assess the risk of local recurrence of intraductal carcinoma of the breast with a large series and a review of literature.We present a retrospective study of 331 cases treated for intraductal carcinoma of the breast. Only patients with at least 5 years follow-up were selected. We were specially interested in recurrence risk factors. In these patients with a long follow-up; pathology was reevaluated with new investigation technique.After a median follow-up of 109 months, 40 local recurrences were observed; these lesions were invasive in 23 cases. Only one patient had recurrence after mastectomy. For the others, they had lumpectomy associated with radiotherapy in 12 cases. Histologic features, grade and therapeutic options were evaluated as risk factors of local recurrence.Follow-up after lumpectomy for intraductal carcinoma was studied. The status of tumor margins was important; irradiation appeared useful, specially in case of high grade carcinoma but further large prospective randomized studies are needed. The use of prognostic index is interesting, but there are still unanswered questions.

A case of intravenous leiomyomatosis of the uterus with extension into the heart discovered in a 34-year old patient who suffered from dyspnea is reported. The findings suggest that intravenous leiomyomatosis originates from the smooth muscle component of uterine veins. Only 30 cases of intravenous leiomyomatosis with intracardiac extension have been reported. Two-dimensional echocardiography showed an abnormal mass in the right atrium. Pelvic echography showed an abnormal mass in the pelvis. In case of cardiac involvement, spontaneous prognosis remains poor. The primary goal of surgery is the complete removal of the tumor. Hormonotherapy should also be considered in case of unresectable residual tumor. A long-term follow-up of patients after resection of intravenous leiomyomatosis is needed because recurrences up to 17 years after primary resection have been reported.

To elaborate a new classification of surgery of soft tissue sarcoma (STS).This was a multicentre study. Purely descriptive terms of surgery of STS have been established. The classification results in a synthesis of surgery terms and conclusion of the pathological report defining the resection (R): R0 = in sano, R1 = microscopic residual disease, R2 = macroscopic residual disease. Validity of the terms has been evaluated by questionnaire, first concerning previous operations, then prospectively during 15 months on the following operations.One hundred and seventy six operating forms established prospectively by eight centres were analyzed. The majority of surgeons were satisfied with the new items. Most of them judged the terms appropriate to surgery. In 96 cases, confrontation between the surgical terms and pathological items was made. Concordance between them was found in 2/3 of the cases. Discordance was observed essentially in cases of re-excision. In all 96 cases the synthesis was judged reliable, permitting treatment adaptation. The study is ongoing. Following propositions of participants, modifications of the surgery terms are included.Subject to confirmation of these promising results, the proposed classification should contribute to optimize treatment of STS.

Important advances have been obtained in the care of soft tissue sarcoma in adults, mainly in the field of locoregional treatment. Surgery or combination of surgery and radiotherapy allow adequate tumor control with preservation of function for the majority of patients. However, the management of locally advanced primaries remains problematic. Moreover, although patients survival mainly depends on the metastatic risk of the disease, controversies remain in definition of pronostic factors as well as in the evaluation of the role of chemotherapy in curative therapeutical strategies. The case reported here allows a discussion of the different modalities of treatment for adults with soft tissue sarcomas and stresses the necessity of a multimodal approach in these patients.

The objective of this phase II study was to determine the efficacy and toxicity of a combination of carboplatin and etoposide as salvage treatment, in previously treated patients with persistent or recurrent ovarian cancer following first-line cisplatin-based chemotherapy.From July 1990 to August 1994, 58 patients were treated with 3-week cycles of chemotherapy consisting of carboplatin (200 mg/m2, D1) and etoposide (120 mg/m2, D1, D2). Criteria for evaluating previous response to cisplatin were strictly defined.The overall response rate was 36%, with five complete responses (CR, 9%), 16 partial responses (PR, 27%) and the median duration of response was 10 months (range: 4 to 38). In the group of patients who progressed during the first year following the diagnosis, the response was 1 CR and 2 PR (12%) and in the group of patients who progressed from the second year after diagnosis, 4 CR and 14 PR (56%), with a median survival of 8.5 and 21 months respectively (p = 0.0013). The response rate was 59% in the potentially platinum sensitive group versus 8.7% in the primary resistant group (0.02p0.05). Myelotoxicity was the main side-effect but did not appear to be cumulative. Grade 3 and grade 4 anemia were observed in 26% and 3% of the patients respectively, neutropenia in 14% and 2% and thrombocytopenia in 14% and 8.5%. One patient died of sepsis associated with neutropenia.Treatment was easily manageable and well tolerated. The advantage of carboplatin and etoposide combination in potentially responsive patients is represented by the reduced nephrotoxicity, neurotoxicity and ototoxicity as compared with cisplatin containing regimen, with durable feasibility in outpatients. This second-line chemotherapy for ovarian cancer is effective as salvage treatment in potentially responsive patients with late recurrent tumors, while paclitaxel is the drug of choice for patients who have developped primary or secondary resistance to platin therapy.

The place of surgery in the treatment of soft-tissue sarcoma is defined in the light of a review of the recent litterature. Usual treatment combines conservative surgery and radiotherapy. The essential risk factor of local recurrence is the quality of surgical resection, defined by the definitive resection margins. The addition of radiotherapy after inadequate surgery can improve local control, but cannot ensure that obtained after adequate surgery. Some limited tumours can be treated by surgery alone, but radiotherapy remains essential in more advanced tumours. Under these conditions, local recurrence rates after surgery alone, surgery and systematic radiotherapy and surgery with radiotherapy, as required are 27%, 28% and 30% respectively. The development of a local recurrence appears to affect survival in tumour with a good initial prognosis, early recurrence determining unfavourable outcome. Serious postoperative morbidity is observed in 14% of the cases and is responsible for delayed treatment and functional disorders. The use of muscle flaps to fill the surgical defects can reduce these complications. Evaluation of the functional results must be based on predefined objective criteria.

To evaluate the place of ovarian transposition by laparoscopy in the treatment of cervical cancers.From March 1992 to November 1994 at Institut Bergonié, 11 patients (mean age: 40 years; 36-44 years) with invasive squamous cell carcinoma of the uterine cervix stages Ib (4 cases) and IIb (7 cases) underwent lateral high ovarian transposition by laparoscopy performed during a staging inter-iliacal lymphadenectomy. There was no complication during surgery but one phlebitis occurred postoperatively. The treatment for the cervical cancer included: brachytherapy (11 cases), external beam radiotherapy (EBRT) (9 cases), surgery (6 cases), chemotherapy (2 cases). Ovarian radiation dosis was calculated and hormonal status assessed.Ovarian preservation was achieved in 30% of the cases. The mean lowest cumulative dosis to the ovaries was 1.78 Gy. Age was the most predictive factor for ovarian preservation.With ovarian laparoscopic transposition, ovarian function can be preserved in selected patients requiring first line radiotherapy for cancer of the cervix. After the age of 40 years, transposition should be restricted to small T1 tumors treated by brachytherapy. When EBRT is required for larger lesions, transposition should be reserved to younger patients.

Between May 1986 and June 1992, 48 patients with soft tissue sarcomas underwent 50 intraoperative interstitial implants in conjunction with conservative tumoral resections. Brachytherapy was part of the initial treatment in 27 cases and was done in 21 other previously treated patients. For the last ones brachytherapy was, in most of the cases, the only treatment in addition to surgery. The implant dose was 40–65 Gy. When combined with external irradiation the mean prescribed dose was 20 Gy (12–25 Gy). With a median follow-up of 33 months, the 3-year actuarial survival rate was 81% and the local disease-free survival 91.7%. Five local failures were observed only in patients with recurrent sarcomas: two were inside the treated volume and three outside (local failure 548=10.4%). Acute side-effects occurred in 11 patients (1148 = 23%), with skin breakdown (two cases) infection and hematoma (one case), infection, lymphocele, secondary skin breakdown and vascular rupture (one case), infection and limited skin breakdown (two cases) and delayed healing (five cases). As a consequence, six patients required reoperation but no amputation was necessary. The functional results were good. Only three patients had a moderate limitation of movement. Late complications occurred in five patients: bone fracture (one case), leg oedemas not interfering with normal activity (three cases), peripheral neuropathy fibrosis related requiring surgery (one case). Therefore, this preliminary report shows that adjuvant intraoperative brachytherapy is feasible and is safe in treating soft tissue sarcomas, even in previously irradiated patients. However, further evaluation is needed to determine the real place of intraoperative implant in the management of soft tissue sarcomas.

From May 1981 through December 1990, 167 patients with ovarian carcinoma were treated with whole abdominal irradiation. All patients of the first group (n = 62) presented with no or minimal (2 cm) residual disease at the time of irradiation. They received whole abdominal irradiation after initial surgery. Residual disease was left after initial surgery for patients of the second group (n = 105). They underwent a cisplatin polychemotherapy regimen followed by second-look laparotomy and abdominopelvic irradiation. The irradiation was performed by a four orthogonal field's technique. Thirty grays were given with a 25 MV photon beam. Boosts were performed in 50 cases (mean dose of 15 Gy); 91% have completed irradiation at the prescribed dose level; 5% had severe intestinal toxicity requiring surgery. The median follow-up was 68 months. The 5-year actuarial survival rate was 50%, 67% group 1.40% group 2. Five-year actuarial survival was 84% for T1, 61.5% for T2, 38% for T3. Five-year survival depended on tumor rest after initial surgery (residual disease 36.5%, no residual disease 70%). For patients in group 2, the size of residual disease at second-look laparotomy was a significant prognostic factor: five-year actuarial survival 76% with negative second-look, microscopic residual disease (positive cytology or random biopsies) 60%, microscopic disease after cytoreductive surgery at second-look 22%, macroscopic residual disease (small nodules) 10%. These results indicate that abdominopelvic irradiation is valuable in the treatment of ovarian carcinoma when there is no macroscopic residual disease after initial surgery or second look laparotomy. To assess the place of radiotherapy, randomized trials comparing whole abdominal irradiation with chemotherapy, watch policy for staged patients is warranted.

The charts of 147 patients with advanced ovarian cancers responding completely (CR) or partially (PR50%) to a primary cisplatin-based chemotherapy are reviewed. All fulfilled our criterias to undergo second-look laparotomy. One hundred patients (group A) underwent second-look laparotomy and 47 patients (group B) other features of control: laparoscopy 37 patients, clinical control ten patients. Apart metastatic spread more frequent in group B (A vs B = 10 vs 32%) and tumor grade 1 more frequent in group B (A vs B = 33 vs 49%), the two groups were well balanced concerning tumor characteristics and treatment features. All patients had received a complementary treatment after the second-look procedures. With a median follow-up of 86 months in group A and 104 months in group B, no difference was found in overall nor in recurrence-free survival. Within group A, 34 patients had achieved pathologic proved complete remission. Their 5-year survival was 73% with an incidence of recurrence of 32%. Second-look laparotomy was found an invasive technique with a 15% operative morbidity. Its therapeutic apport seems absent and the diagnostic role limited to indication of radiotherapy in CR patients. Second-look laparotomies should be reserved to trials evaluating its proper place but should not be used systematically to assess tumor response to chemotherapy. The good 5-year survival of the CR mi group suggest the beneficial impact of complementary treatment, but prospective trials are needed to evaluate the place of this treatment.

Activity in a surgical department can be evaluated quantitatively, but is should also be assessed qualitatively. One way to control the quality of care is to determine as accurately as possible the incidence of pre- peri- and post-operative complications and to analyse these date in a critical comparative study. This was accomplished in the surgical department of the Fondation Bergonié, Bordeaux during three test periods over the last five years--March 1987 (127 patients), June-July 1989 (276 patients), and June 1991 (147 patients). Results of this analysis cannot validly be compared with those of other departments with different patient recruitment and activity functions. However, this study within a department with regular, homogeneous activity did demonstrate, over a period of several years, a clear reduction in operative mortality, essentially by improved control of infectious complications by the extensive use of prophylactic antibiotic therapy for all surgery with a septic risk or for debilitated patients. Results also demonstrated the low cost effectiveness of routine pre-operative exploratory examinations.

From 1975 to 1988, 144 patients naive of treatment, with non-metastatic soft tissue sarcoma were treated at Fondation Bergonie by surgery, followed by radiotherapy and without chemotherapy. An analysis of prognostic variables was done on this population to determine patients for whom an adjuvant chemotherapy would be relevant. Prognostic variables in overall survival (OS), metastasis-free survival (MFS), disease-free and local free recurrence survivals were analysed by univariate and multivariate analysis. In multivariate analysis using Cox's model, only tumour depth and tumour grade were significant with the MFS end point, while tumour depth, tumour grade and tumour site were significant when considering OS. A predictive stratification for patients is proposed: a favourable prognostic group with grade 1 tumour or superficial, grade 2 tumour (5-year OS: 97.8%; 5-year MFS: 100%); an intermediate prognostic group with deep, grade 2 tumour or superficial, grade 3 tumour (5-year OS: 58.8%; 5-year MFS: 48.1%); and finally a poor prognostic group with deep, grade 3 tumour (5-year OS: 31.7%; 5-year MFS: 34.1%). Patients in the intermediate and poor prognostic groups who present a high metastatic risk are to be considered for adjuvant chemotherapy trials.

A 64 year-old man with a metastatic clear-cell renal carcinoma experienced low intestinal bleeding. The endoscopy revealed a polypoid mass in the left colon which proved to be a metastasis of the renal carcinoma. This is an uncommon cause of intestinal hemorrhage, and a rare localization of metastatic deposits.

Between 1975 and 1985, we have treated 157 patients with carcinoma of the cervix T1. The size of the tumor was always equal or less than 30 mm. Our patient underwent Cesium 137 brachytherapy with Fletchers applicators followed by a modified radical hysterectomy and pelvic lymphadenectomy 4 to 6 weeks later. Intracavitary brachytherapy was performed within three days (low dose rate 0.8-1 Gy/h). The median 60 Gy Isodose was: 65 mm height, 58 mm width and 29 mm thickness. At surgical time we mentioned that vaginal cut out was 2-3 cm and pelvic lymphadenectomy limited to external iliac nodes. The 5 and 10 disease Free Survival was respectively 91.6 and 89.4%. We observed 14 relapses, five were distant metastases only. The tumor size and pelvic node involvement were the main prognostic factors in our data. The sterilization of the cervix wasn't of prognostic value. Complications occurred in 22 patients, 2 (1.3%) were severe urinary injury.

This paper is a review about the relationship that may exist between taste alterations in cancer patients and cancer itself, surgery, chemotherapy, radiotherapy or symptomatic treatments. Therapeutic strategies dealing with patients with taste alterations are also discussed.

One hundred and seven patients have been treated by the peritoneovenous shunt (PVS) : 54 patients from 1979 to 1984 (P1) and 53 patients from 1985 to 1990 (P2). The mean age was 58 years (25-79 years) and 73 % of the patients had a cirrhosis of alcoholic origin. The mortalities at two weeks and one month were 22 % and 26 % for P1 and 6 % and 11 % for P2. The risk of operation was related to the importance of hepatic and kidney insufficiency and to the importance of hyponatremia. Long term outcome depended on the causal illness. At short term, the morbidity can be reduced and the PVS should be indicated earlier in the progression of the illness.

From October 1985 to October 1988, 31 patients with a soft tissue sarcoma of extremities were treated in our institute by conservative resection and post-operative radiation therapy. The initial target volume encompasses the entire musculoskeletal area occupied by the tumor. The compartmental definition of this initial target volume is based on clinical, radiographic, histopathologic and operative findings. We analyzed the irradiated volume in terms of the anatomical definition and feasibility. We then evaluated the distribution of the dose in the irradiated volume. The variation of the dose is always less than 10%. Accordingly, the range of dose in the irradiated volume varies from 45 to 50 Gy in the compartmental volume after a complete resection, and from 55 to 60 Gy in the tumor bed after a marginal or incomplete resection. For this series, the median follow-up is 27 months. We observed 3 distant metastases and 1 progressive disease in the irradiated volume. No locoregional recurrence appeared in the margins or outside the irradiated volume. These preliminary results validate the compartmental definition of the initial target volume. Furthermore, they point out the lack of opportunity to encompass tendinous insertions in the irradiated volume and to boost the scar. Finally, the definition of optimal dose for the control of microscopic residual tumor is discussed.

A series of thirty consecutive epithelial ovarian cancer patients were reviewed after long-term follow-up (more than 5 y) since their second-look operation (SLO). All patients had advanced tumors (stages IIb-IV). Primary chemotherapy consisted of a cisplatin-associated regimen. For all patients adjuvant treatment had been planned after completion of the SLO. Mean follow-up after SLO was 68 months (47-103 months). Tumor status at SLO divided the patients in 2 subgroups: Group A = 13 patients (43%), with no evidence of histologically proved disease at time of operation (NED); Group B = 17 patients (57%), with macroscopic persistence of tumor. Survival was significantly better in the first group than in the second (77% at 5 yr vs less than 25%). Recurrence rate in the NED group was 7.7% (1 recurrence at 32 months). Eight of 17 patients with gross tumor at SLO underwent satisfactory resection. However, recurrence rate was high (75%) and survival rate was low (25% at 5 yrs). This result was not significantly better than that of patients with no optimal resection at SLO (9 patients, survival 22%). Second effort resection at SLO does not seem to be beneficial in these patients after partial failure of initial chemotherapy with cisplatin. The usefulness of systematic second look operations is discussed. Controlled randomized trials should be made to determine the exact role of SLO in ovarian cancer treatment.

A series of 105 consecutive patients with superficial soft tissue sarcomas was analysed to assess the evolution of these tumors. There were 56 men and 49 women, aged 16 to 80 years (median: 56.4 years). Tumor localizations were 59 limbs (56.2%) and 41 non-limbs. The median tumor size was 3 cm (range 1 to 15 cm). Histological types were mainly malignant fibrous histiocyto-fibromas (n = 39/36.8%), leiomyosarcomas (n = 20/18.9%), dermatofibrosarcomas protuberous (n = 8/7.5%). According to the FNCLCC grading, tumor grade was: grade 3 = 24, grade 2 = 54, grade 1 = 28. With a median follow-up of 112 months (range 19 to 321 months), the 5-year overall and disease-free survival were 75% and 46%. In mono-factorial analysis, tumor grade is the only predictive factor for overall survival (grade 1 vs grade 2: P = 0.02; grade 2 vs grade 3: P = 0.0002), and for metastasis-free survival (grade 1 vs grade 2: P = 0.05; grade 2 vs grade 3: P = 0.0006). For grade 2 tumors, metastases occurred only after a deep, local recurrence. Age, tumor size, tumor localizations were not statistically significant. For the local relapse-free survival, tumor size ( P = 0.0006).

Methods From 1975 to 1992,361 patients (pts) had their initial treatment at Institut Bergonie for non metastatic STS. There were 210 males and 151 females at a mean age of 50 years (16–87 years). 59% of the tumours were localized in the extremities. All pathological slides have been centrally reviewed. Grading according to the FNCLCC system was: G1 (18%), G2 (44%), G3 (38%). The local treatment combined surgery and radiotherapy in 83% of the cases. Surgery was conservative when possible. Marginal surgery was performed in 45% of the cases, wide excision in 48%. Compartmental radiotherapy was performed at a dose of 50 Gy, associated with a local boost (external beam, intraoperative or brachytherapy) when surgery was marginal. Chemotherapy was given in 126 pts (35%), in 60 of whom preoperatively. Results Amputation was necessary in only 7 pts (2%). Complete remission was obtained in 97.5%. Severe local complications occurred in 26 patients (7.2%). With a median follow-up of 6 years (1–20 years) local recurrence occurred in 21. 4% of the cases, and metastasis in 28.7%. Actuarial 5-year overall and disease free survival are 66% and 59%. The function of the treated members was good in 92% of the pts. In univariate analysis, no difference was seen in local recurrence after marginal vs large excision when radiotherapy was done. Conclusion These treatment results compare favourably to those found in the literature. Satisfying functional outcome without amputation can be obtained by a multidisciplinary treatment approach.