Bulletin du cancer
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Randomized Controlled Trial Clinical Trial Controlled Clinical Trial
Total body irradiation in bone marrow transplantation: fractionated vs single dose. Acute toxicity and preliminary results.
The usefulness of total body irradiation (TBI) plus chemotherapy as a preparative regimen prior to bone marrow transplantation has been widely documented. However, the procedure can be highly toxic. Fractionated and low dose rate TBI has been said to enhance therapeutic ratio by increasing normal tissue tolerance and increasing leukemic cell kill. ⋯ Other results obtained to date are as follows: an incidence of interstitial pneumonitis of 39% and 31% (ns); relapses of 10% and 20% (ns), and mortality of 55% and 60% for each group respectively. An interesting finding was that IP was associated with acute grade II-IV graft vs host disease in 87% and 100% of cases of group A and B, respectively. We conclude that fractionated TBI is at least as effective as single dose TBI as a conditioning regimen; however, only randomized trials would allow definitive conclusions.
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The authors treated 188 patients with osteosarcoma by chemotherapy followed by surgery and additional chemotherapy (Rosen's T regimen). In 14% of cases, infectious, neurologic or cardiac complications were observed, which resulted in death in 2% of the patients. Forty-six per cent responded well to the primary chemotherapy, 76% of which are alive and disease-free, as opposed to merely 42% of the bad responders.
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Between April and September 1986, 60 patients with osteosarcoma have been treated according to the T10 protocol in the Pediatrics Department of the Gustave Roussy Institute in Villejuif, France. Limb sparing could be achieved in 49 patients and amputation was necessary in 11. The necrosis of the primary tumor was total or subtotal in 33 cases and incomplete in the 27 others. With a median follow-up of 28 months, the actuarial survival is 85% at 48 months and the actuarial disease-free survival is 58%; the disease-free survival of "good responders" is 75% and 32% for "bad responders".
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Adjuvant chemotherapy after apparently complete resection of gastrointestinal cancer may be theoretically justified by the high rate of local and metastatic recurrences. However, the results of controlled trials are generally disappointing, even if some of them have recently suggested some hope, chiefly for adjuvant therapy in gastric cancer. Confirmation of these preliminary results is needed before considering adjuvant therapy as routine treatment in digestive tumors.
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Careful assessment is a necessary preliminary to treatment; pain may be caused by a variety of mechanisms or associated with a non-malignant condition. In the majority of patients treatment should be planned on a multimodality basis. The fact that pain is a somato-psychic phenomenon must not be forgotten. ⋯ When used as described, escalation of dose (tolerance) is not a practical problem. Physical dependence does not prevent the downward adjustment of dose should this become feasible as a result of non-drug intervention. Psychological dependence (addiction) does not occur if the patient is closely supervised and given adequate emotional support.