Search

The method of minimization of action is a powerful technique of proving the existence of particular and interesting solutions of the n-body problem, but it suffers from the possible interference of singularities. The minimization of action is an optimization and, after a short presentation of a few optimization theories, our analysis of interference of singularities will show that: (A) An n-body solution minimizing the action between given boundary conditions has no discontinuity: all n-bodies have a continuous and bounded motion and thus all eventual singularities are collisions; (B) A beautiful extension of Lambert’s theorem shows that, for these minimizing solutions, no double collision can occur at an intermediate time; (C) The proof can be extended to triple and to multiple collisions. Thus, the method of minimization of action leads to pure n-body motions without singularity at any intermediate time, even if one or several collisions are imposed at initial and/or final times.

"La hipertermia es una de las terapias utilizadas para combatir elcáncer, sin embargo, existe la necesidad de mejorar la técnica paraevitar los daños a los tejidos sanos debidos a la elevación de temperatura.El trabajo presentado, muestra diferentes alternativas paralograr una hipertermia electromagnética local. Se muestran los resultadosobtenidos de la utilización de diferentes materiales quepueden introducirse en el tumor, o cerca de él, con el fin de aprovecharel campo eléctrico y el campo magnético de la energía electromagnéticaradiada. Estos compuestos son: cloruro de sodio, ferritay ferrofluidos. Se muestran los resultados obtenidos de lasmediciones de temperatura realizadas en un fantoma TX150 basadosen el método del impulso único."

La tomographie conique souleve la problematique de la variation de la distension rectale et vesicale entrainant une variabilite de la dose delivree dans la prostate et les vesicules seminales et un risque de toxicite majoree. Nous proposons un protocole d’education du patient. Lors de la consultation d’annonce medicale, une fiche de recommandations pour la scanographie de centrage et les seances d’irradiations est remise au patient, de meme qu’une fiche dietetique de confort intestinal. Lors de la consultation paramedicale d’annonce differee, une demi-heure environ avant la scanographie, le patient vide sa vessie et si possible son rectum (sans lavement) et boit deux verres d’eau (350 mL) dont l’heure de la prise est notee. Puis, une scanographie « low dose » centree sur la prostate (40 coupes) est realisee afin de verifier le rectum et la vessie selon des criteres predefinis (diametre rectal anteroposterieur inferieur a 4 cm a la symphyse pubienne, vessie ne devant pas depasser si possible le segment passant par le bord superieur de la prostate et s’etendant de 4 cm vers la tete). L’acquisition apres injection peut etre lancee et l’heure notee determinant l’intervalle entre l’horaire de vidange vesicale et la seance. Au poste de traitement, le manipulateur interroge le patient chaque jour sur le respect des consignes rectales et vesicales ; l’acquisition de la tomographie conique a j1, j2, j3 permet le recalage osseux, la verification vesicale et rectale puis le recalage des tissus mous par le medecin. Des manœuvres correctives sont faites en cas de mauvais remplissage vesical et vidange rectale. Si la difference de recalage est de plus de 5 mm, une tomographie conique quotidienne est realisee, sinon le rythme devient hebdomadaire. Ce protocole de remplissage vesical et vidange rectale semble applicable au prix d’un investissement important des manipulateurs.

Objectif Controler le positionnement des applicateurs places dans le patient et realiser la planification de dose, au decours d’un traitement de curietherapie de haut debit de dose par l’utilisation de l’imagerie embarquee d’un accelerateur, la tomographie conique (CBCT), avec le projecteur de source installe dans le bunker. Materiels et methodes Le centre hospitalier universitaire de La Reunion s’est equipe d’un projecteur de curietherapie de haut debit de dose (GammaMed™, Varian) installe temporairement dans un bunker disposant deja d’un accelerateur (Clinac® 2100 C/D, Varian) avec imagerie embarquee. Les systemes de securite mis en place ne permettent pas le fonctionnement des deux equipements (projecteur de curietherapie et accelerateur) simultanement. Dans un premier temps, la planification de dose est realisee a partir d’images realisees par le scanographe dedie du service. La tomographie conique est realisee juste avant le traitement de haut debit de dose afin de controler le positionnement des applicateurs. Dans un second temps, l’utilisation de la tomographie conique sera etendue a la realisation de la planification de traitement. Un controle de positionnement et une dosimetrie en temps reel seront alors effectues a partir des tomographies coniques realisees par l’accelerateur, juste avant la curietherapie de haut debit de dose. Resultats Nous presenterons nos premiers resultats cliniques de faisabilite ainsi que les controles qualite associes a la tomographie conique de l’accelerateur. Conclusion Cette solution pourrait etre implementee dans d’autres services et surtout dans les services de radiotherapie des DOM/TOM (departements et territoires d’outre-mer) ou le nombre de curietherapies ne permet pas de rentabiliser la construction d’un bunker de haut debit de dose dedie. L’utilisation de la tomographie conique d’un accelerateur est un element supplementaire qui permet d’ameliorer le controle et la qualite des traitements de haut debit de dose realises.

Medulloblastoma is a malignant neuro-ectodermal tumor classically considered as a pediatric tumor. Adult medulloblastoma is rare. This low incidence results in a lack of data concerning the management of treatment. We report our experience and propose a review of the literature to clarify the main therapeutic options that are nowadays suggested.We reviewed 22 adult patients treated for cerebellar medulloblastoma between 1979 and 1999. Actuarial relapse-free and overall survival were determined by the Kaplan-Meier method. Prognosis factors were studied by Log- Rank test.The five years relapse free and overall survival rates were respectively 63.1% and 81.3%. These rates are superior to those reported in the literature. None of the studied factors (age, gender, histological subtype, total or partial surgery, presence of a CSF derivation device, radiotherapy, chemotherapy) were significantly associated to remission or survival. However our statistical results should be interpreted with caution in this small population.Adult medulloblastoma prognosis seems to improve since chemotherapy has been introduced in the therapeutic protocols. Prospective and multicentric studies should determine the exact pattern of treatment.

Intensity modulated radiation therapy (IMRT) is an advanced method of conformal radiotherapy. It permits optimal dose distribution to the target volume while preserving surrounding normal tissues. IMRT, with a multileaf collimator, can be realised in two different ways: either the segmented mode, which consists of combining small elementary static field, or the dynamic mode, which consists of moving the leaves while irradiating. The purpose of this work was to study these two methods of modulation on a Varian linear accelerator equipped with a collimator consisting of 40 pairs of one-centimetre-wide leaves. The measurements, obtained by using a diode array, showed that the quality of the irradiation in the dynamic mode does not depend on either the dose rate or the duration of the irradiation. In the segmented mode, weak magnitude segments are preferable, but increase the errors in the delivered dose. Comparisons of various profiles showed that the measured profiles are consistent with those programmed. Both modes seem to be equivalent for step-shaped profiles. In the case of profiles with constant slope, the segmentation generated by the segmented method deteriorates the profile. Even though the choice of technique is strongly dependent on the material available, the dynamic mode presents greater flexibility of use and has been chosen in our institution for IMRT.

A beautiful plane eight-shaped orbit has been found by Alain Chenciner, Richard Montgomery and Caries Simo through the minimisation of the action between suitable limit conditions. The three masses are equal and chase each other along the eight shape. This procedure can be generalized and leads to a family of three-dimensional periodic orbits with three equal masses and with 12 space-time symmetries per period. The property of a unique orbit for the three masses is conserved in a suitable uniformly rotating set of axes. The eight-shaped orbit represents the end of the family, its beginning being the classical Lagrangian solution with three equal masses and with a uniformly rotating equilateral triangle.

Cardiovascular mortality, the principal cause of early death in diabetics, is multifactorial. A prospective study was undertaken to analyse the different factors of excess cardiac complications in 40 patients with type 2 diabetes, whatever the symptomatology, by making an inventory of the cardiac abnormalities (systolic and diastolic left ventricular function, left ventricular hypertrophy, abnormalities of myocardial perfusion, heart rate variability and arrhythmias). Patients underwent 24 hour Holter monitoring, high amplification signal averaged electrocardiography, echocardiography, Thallium scintigraphy with a dipyridamole test followed by coronary angiography when positive. Patients were aged 60 +/- 8 years, diabetics for 11.8 +/- 6.8 years, and had associated cardiovascular risk factors: 85% were obese, 75% were hypertensive, 62.5% had hypercholesterolaemia and 60% were smokers. The HbA1C was 9.2 +/- 19%. An increased left ventricular mass was observed in 34.2% of patients. The left ventricular ejection fraction was normal (59.1 +/- 6.8%); 69.7% of patients had left ventricular diastolic dysfunction. Reduced heart rate variability was observed in 51.8% of cases. Late ventricular potentials were recorded on high amplification signal averaging in 39.5% of patients; 25.6% had significant ventricular extrasystoles and 52.2% had atrial extrasystoles. Twelve patients (45%) underwent Thallium myocardial scintigraphy with a positive dipyridamole test, 8 of whom had coronary lesions on angiography. The excess cardiac complications of diabetes is mainly due to ischaemic heart disease aggravated by autonomic neuropathy, left ventricular diastolic dysfunction, arrhythmias and left ventricular hypertrophy. In future, larger series are required to demonstrate that this detection can guide therapeutic intervention and reduce cardiac morbidity and mortality of diabetics.

The lack of new highly efficacious drugs for cancer treatment promotes the search for innovative therapeutic modalities. The authors reported the results leading to the definition of parameters needed to demonstrate a possible radiopotentiation by topotecan (TPT) on two representative human rhabdomyosarcomas (RMSs) xenografted into nude mice. Experimental studies of radiopotentiation with different doses of topotecan showed that concomitant association of topotecan and RT for 5 consecutive days provided a synergistic therapeutic effect. Response rates were statistically higher with the radiochemotherapeutic combination (P0.001). Efficacy enhancement factors of this combination compared with the sum of the antitumoral activity of these treatments separately administrated were 1.54 and 1.60, respectively, on both rhabdomyosarcomas. Moreover, the efficiency of the combination of radiotherapy at the dose of 20 Gy with topotecan (12.5 mg/kg) was not statistically different from that of radiotherapy at the dose of 40 Gy. According to microscopy results, the analyses performed at different periods after topotecan treatment alone, radiotherapy alone, and their combination seemed to show that tumoral repopulation by malignant cells is as fast as the dose of radiotherapy and/or topotecan is low. Furthermore, lesions observed with the dose of 40 Gy were similar to those obtained with the association of topotecan at the dose of 12.5 mg/kg and radiotherapy at the dose of 20 Gy. In conclusion, all clinical and pathological results are consistent with a radiopotentiation effect of topotecan on the two xenografted human rhabdomyosarcomas and are currently leading to the design of clinical studies.

Cerebral sulci identification process is based on several formal rules: it consists a series of steps allowing the identification of the major sulci. The process may be variable for each of us and we propose to read the images in certain order starting with the frontal lobe and its superior frontal gyrus than precentral and central gyri followed by the lateral fissure. Then the insular, lateral parietal and medial hemispheric regions. Finally the major sulci within the temporal and occipital lobes are described in the frontal plane. This presentation indicates the principal rules of cerebral lobes'identification, the basis of variability perception and the localization of small lesions allowing an accurate correlation with clinical findings and a suitable therapeutic procedure.

To evaluate the best strategy for treatment of sarcoma that occurs after radiation therapy.Records were retrospectively reviewed for 80 patients with a confirmed histologic diagnosis of sarcoma that occurred after radiation therapy performed during 1975-1995. The patients were treated for breast cancer (n = 33, 42%), non-Hodgkin lymphoma (n = 9, 11%), cervical cancer (n = 9, 11%), benign lesions (n = 4, 5%), or other tumors (n = 25, 31%). Sarcoma occurred after a mean latency of 12 years (range, 3-64 years), with most (70%) developing in the soft tissue. Treatment included surgery (28 patients), surgery and chemotherapy (18 patients), chemotherapy only (15 patients), and radiation therapy (14 patients).By the end of the study, 51 patients were dead, including 46 due to sarcoma. Median survival was 23 months. Overall survival rates at 2 and 5 years, respectively, were 69% and 39% for patients treated with surgery, 10% and 0% for those treated with chemotherapy, and 52% and 35% for those treated with surgery and chemotherapy (P =.001). The 2- and 5-year rates for survival without recurrence were 54% and 32%, respectively.The results confirm the beneficial effect of surgery. Further study is needed to explore the roles of combined treatments.

A 63-year-old man presented suddenly and spontaneously an isolated painless oculomotor palsy of the nerve abducens. As no etiology could be suspected a head MRI was performed. It showed a T1 hypersignal of the intracavernous segment of the internal carotid artery with a double-lumen pattern typical of dissection. The patient was treated with aspirin and recovered from clinical symptoms in 10 weeks. A control MRI was performed 3 months after the onset of symptoms and showed the regression of the images of dissection. There was no ischemic lesion of the brain. This case underlines the diversity of the symptoms of spontaneous dissections of cervicocephalic arteries, especially absence of pain, palsies of cranial nerve that are not always limited to lower cranial nerve, and existence of dissections limited to the intracranial segment of the carotid artery. It suggests the interest of MRI in the diagnosis of isolated oculomotor nerve palsies.

The purpose of this study was to determine the clinical and prognostic features of leukemias and preleukemic states, whatever the mode of development, observed in patients after treatment of breast cancer.A retrospective multicentric analysis was made of 121 patients treated for breast cancer and who later developed leukemia or a preleukemic state. Initially, 44 patients had undergone mastectomy, 72 had conservative surgery and 119 had locoregional irradiation. At least one chemotherapy session was performed in 90 patients and 48 had received tamoxifen. The risk of relapse of breast cancer was high, moderate or low for 44, 46 and 24 patients respectively (data not available for 7 patients).By class, the hematology diseases found were: myelodysplasia (n = 9), refractory anemia with blast excess (n = 7), acute lymphoblastic leukemia (n = 6), acute myoblastic leukemia (n = 93 including a majority of type 2 and type 4). For acute myeloblastic leukemia, mean delay to onset was 65 and 37 months respectively without and after chemotherapy. The prognosis of these cases of leukemia and preleukemic states was poor with an overall death rate of 86%.In light of the recent development of indications for adjuvant chemotherapy even for subgroups of patients at moderate risk, it is important to more precisely assess the absolute benefit in terms of survival compared with the risk of severe complications, particular secondary leukemia. In the future, a systematic registry and a case-control study are required.

The outcome of head and neck malignancies is closely related to the achievement of local tumor control. The occurrence of severe late complications is the consequence of the anatomic vicinity between dose-limiting normal tissues and the tumor, thus reducing the curative potential of radiotherapy. Conformal radiotherapy is presently actively investigated as a way to improve the dose distribution in head and neck malignancies (especially when originating from the nasopharynx or the sinuses) while protecting healthy organs. Such an approach requires a chain of sophisticated procedures, including efficient quality assurance programs, in order to achieve the proper degree of safety. The relatively limited clinical studies published to-date have already confirmed the advantage of conformal radiotherapy in terms of dose delivery. The development of beam intensity modulation is likely to further contribute to the improvement of the therapeutic ratio.

Adjuvant treatment for intramedullary tumours is based on radiotherapy. The place of chemotherapy in this setting has yet to be determined. Between May 1992 and January 1998, eight children with unresectable or recurrent intramedullary glioma were treated with the BB SFOP protocol (a 16-month chemotherapy regimen with carboplatin, procarbazine, vincristine, cyclophosphamide, etoposide and cisplatin). Six children had progressive disease following incomplete surgery and two had a post-operative relapse. Three patients had leptomeningeal dissemination at the outset of chemotherapy. Seven of the eight children responded clinically and radiologically, while one remained stable. At the end of the BB SFOP protocol four children were in radiological complete remission. After a median follow-up of 3 years from the beginning of chemotherapy, all the children but one (who died from another cause) are alive. Five patients remain progression-free, without radiotherapy, 59, 55, 40, 35 and 16 months after the beginning of chemotherapy. The efficacy of this chemotherapy in patients with intramedullary glial tumours calls for further trials in this setting, especially in young children and patients with metastases. © 1999 Cancer Research Campaign

TheStandards, Options and Recommendations(SOR), started in 1993, are a collaborative project between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcomes for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary experts group, with feedback from specialists in cancer care delivery. The initial guidelines are being updated in case of new evidence.To update the clinical practice guideline [39] with definitions of new Standards, Options and Recommendations for the use of recombinant human erythropoietin (rHuEPO) in oncology.Data have been identified by literature search using Medline, Current Contents, Embase, Cancerlit (march 1996-march 1999). The main end points considered were hemoglobin level, haematocrit, quality of life, transfusion requirements, incidence and length of hospital stays, efficacy of cancer treatment, safety and costs. Once the guideline was updated and defined, the document was submitted to 42 reviewers for peer review, and to the medical committees of the 20 French Cancer Centres for review and agreement.The new key recommendations are: 1) The use of recombinant human erythropoietin in oncology is an alternative to treat chemotherapy-induced anemia when the chemotherapeutic regimen contains platinum; 2) Cancer-induced anemia reduces patients' quality of life. Treatment of anemia by transfusions of erythropoietin may improve quality of life; 3) We recommend assessment of haemoglobin levels during radiation therapy and the possible use of erythropoietin to optimise the efficacy of radiation therapy; 4) Erythropoietin is effective in others pathologies (multiple myeloma, non-Hodgkin lymphoma, non-platinum based chemotherapy.) and also in pediatric patients but the risk/benefit ratio for anemia therapy (i.e. transfusion or erythropoietin therapy) must be analysed for each individual; 5) We recommend an economic analysis of the need of erythropoietin within the context of the french health care system.

Two patients presenting with an intrasellar epidermoid cyst and operated on through a transsphenoidal approach, are reported. Problems regarding pathological controversies about the differential diagnosis (particularly craniopharyngiomas) are addressed. In order to establish the adequate preoperative diagnosis, the interest of MRI is discussed.

Considering that BPH is a highly common condition in the urological practice, that demographic changes further emphasise this feature and that the analysis of costs, funding and health care management are becoming increasingly under scrutiny, it is important to know the cost per procedure of the most commonly used therapeutical approaches and the impact of the complications on such cost.1. To know the cost per procedure of prostate TUR as PBH treatment. 2. To know the percentage of complications involved and the way in which they impinge on cost.Considering all data gathered from the annual surgical activity in our service with regard to this procedure and the percentage of complications after studying 105 cases over an evolution period of 6 to 50 months, the Planning and Management control Unit at the H.C.S. reported on the expenditure generated by this activity.The cost per procedure in prostate TUR due to BPH in our environment is 191.030 pesetas at 1997 value. Morbidity affects 23% patients. Diagnosis and treatment of complications increases the overall cost by 7% thus reaching 205.096 pesetas.The knowledge of the above results provides important data on the expenditure generated by the activity of our Service for funding and management purposes. It also allows us to perceive therapeutical results as a measure of quality control, and to redefine those actions that will allow us to improve our results.

Meatal stricture is not an uncommon condition in the clinical practice, the classical treatment being meatotomy. The failure of the technique and the changes in the quality of the urinary stream have forced us to perform a meatoplasty procedure with pedicle flap from penial skin as described by Jordan, using intravenous local anaesthetics, thus avoiding hospitalization and reducing the overall cost of the procedure. From a total of 23 patients who (between May 1995 and April 1998) required surgery due to meatal stricture, 11 patients underwent meatoplasty and the rest meatotomy. None of the patients in the former group developed re-stenosis, and achieved a mean improvement of Q max in the flowmetry performed three months after the procedure of 23 mL/sg. vs the 10.5 mL/sg. of patients undergoing meatotomy. This difference is statistically significant at p = 0.02. Cost saving when surgery is conducted in the day hospital is 122,302 pts/procedure vs 215,182 pts/procedure if the patient had to remain in hospital for 3 or 7 days. Compared to the lower cost of meatotomy (39,308 pts/proc.) or meatoplasty (57,525 pts/proc.), it must be emphasised that the management of complications in the first case is 6,816 pts/patient vs 1,724 pts/patient required for cures in the case of Jordan's technique. It was concluded that pedicle flap meatoplasty is an efficient and definitive technique in the treatment of meatal stricture.

Epileptic seizures occur in 5-15% of individuals drinking alcohol. The majority are related to withdrawal, after heavy drinking, but these seizures may be indicative of an underlying structural disease, and always need diagnostic investigations. This type of fit does not require long term anticonvulsant therapy. More than 20% of newly diagnosed epilepsies in adults are alcoholic epilepsies, which concern less than 10% of alcoholic patients. Post-traumatic epilepsy is frequently intricate. Long term anticonvulsant therapy may be indicated, but is only possible if abstinence is acquired. Rare syndromes have been described, which specificity has not been demonstrated. Excessive drinking may provoke seizures in epileptics, whereas moderate or occasional use of alcohol may be not detrimental.

The tests of general relativity have two main purposes: A) To verify, or not, some consequences of the general relativity. The STEP experiments (space tests of the equivalence principle) belong to this first class of tests. B) To allow us to choose among the numerous relativity theories that have been proposed since 1916 and that are competing with that of Einstein.

In a retrospective analysis, our aim was to evaluate the immediate tolerance and the early and late complications of abdomino-pelvic radiotherapy in the Centre Alexis-Vautrin (France).From 1st January 1983 to 31st December 1993, 117 patients were treated at Centre Alexis Vautrin in Nancy for epithelial ovarian cancer by abdominal and/or pelvic irradiation after surgery. They were aged from 24 to 85 with a median of 56 years. There were ten patients with stage I (9%), 28 patients with stage II (24%), 60 patients with stage III (61%) and 19 patients with stage IV (16%) disease. Results of surgery were determined as follows: satisfactory with absence of tumoral residuum in 26% cases (30 patients) and with residuum inferior to 20 mm in 46% cases (52 patients; incomplete in 26% cases (31 patients) either because of residuum superior in 20 mm and/or incomplete surgery; and not evaluable in 3% cases (four patients). Seventy-seven patients were sent to the Centre for postoperative treatment (66% patients of the series), 48 of them (62.4%) after non-satisfactory surgery, 29 after satisfactory surgery (37.6%). Chemotherapy was administered to only 104 patients (89% cases), and contained platinum salts and cyclophosphamid for 87% of these patients. Fourteen patients (12%) received a single irradiation dose after surgery: three in stage I, three with poor evaluation of the disease in the initial stage, three with medical contraindications to chemotherapy treatment, six with contraindications due to advanced age (?? Makes 15 ). Histologically, 46% of patients had a serous adenocarcinoma, 9% a mucinous adenocarcinoma, 11% an endometrioid adenocarcinoma, 2% a clear cell adenocarcinoma, 1% an undifferentiated adenocarcinoma, and 31% an epithelial carcinoma without any other indication. The histological grade which was recently introduced was rarely indicated. Complementary radiotherapeutic treatment consisted of pelvic irradiation for 14 patients (12%), abdomino-pelvic irradiation for 63 patients (54%), and total abdominal irradiation with a pelvic boost for 40 patients (34%).The immediate tolerance to irradiation can be considered as globally satisfactory since 9% of the patients (ten cases) had no problems and 64% of the patients developed a minor intolerance easily controlled by symptomatic treatments. There were also digestive complications: nausea, vomiting and diarrhea for 66% of the patients (50 cases); to a lesser extent, 20% of the cases experienced associated digestive and hematological complications (15 patients); 9% isolated hematological troubles such as anemia (seven patients); 4% digestive complications (three patients) and 1% hematological and urinary digestive troubles (one patients). Late irradiation sequelae were evaluated for 89 patients with a follow-up lasting from 4 months to 11 years. Sixty-six patients had no sequelae, eleven patients had minor tolerability problems--mainly digestive for more than half of them. Five patients presented severe complications, including hematological problems such as chronic thrombopenia in two cases, urinary-problems in two other cases, and one patient presented with a case of histologically proven malabsorption. Two patients presented major problems; one case of radic cystitis and one of radic bowel. Two patients died of iatrogenic causes: one of induced leukemia, the other of treatment-induced digestive and renal complications. The overall survival rate was 30% at 5 years and 22% at 10 years. It was 90% at 5 and 10 years for stage I patients, 60% at 5 years and 30% at 10 years for stage II patients, 22% at 5 years and 8% at 10 years for stage III patients, and finally 10% at 5 years for stage IV patients.In this retrospective analysis of 117 epithelial ovarian cancers, treated over 10 years and which all received pelvic and/or abdominal irradiation, we can conclude that this treatment is globally well tolerated and that it yields a

The "Standards, Options and Recommendations" (SOR), started in 1993, are a collaborative project between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcomes for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary experts group, with feedback from specialists in cancer care delivery.To develop a clinical practice guideline with definitions of Standards, Options and Recommendations for the use of recombinant human erythropoietin (rHuEPO) in oncology.Data have been identified by literature search using Medline (up to march 1996) and Current Contents (up to october 1996) and personal references lists. The main end points considered were hemoglobin level, haematocrit, quality of life, transfusion requirements, incidence and length of hospital stays, efficacy of cancer treatment, safety and costs. Once the guideline was defined, the document was submitted to 39 reviewers for peer review, and to the medical committees of the 20 French Cancer Centres for review and agreement.The key recommendations are: 1) the use of recombinant human erythropoietin in oncology is validated for chemotherapy-induced anemia when the chemotherapeutic regimen contains platinum. In other cases, we recommend to suggest patients participating in prospective clinical trials; 2) for chemotherapy (platinum based)-induced anemia, the benefits/risks ratio for anemia therapy (i.e. transfusion or erythropoietin therapy) must be analysed for each individual patient; 3) we recommend participation in studies to identify predictive factors for non-response to erythropoietin therapy to select non-responding patients; 4) to investigate the clinical benefit of erythropoietin therapy for anemia due to intensive cytotoxic chemotherapy and radiation therapy, we recommend to suggest patients participating in large multicentre phase III trials; 5) at the present time, there is insufficient evidence to recommend the use of erythropoietin therapy in children.

From 1975 to 1996, 98 patients with infiltrative vesical carcinomas were treated at the Centre Alexis Vautrin by conservative surgery and interstitial brachytherapy (192lr). The mean follow-up was about eight years. From this retrospective non randomized study, we tried to determine the tolerance to this treatment.There were 86 men and 12 women. The mean age was 63 years. We found three pTis tumors, 28 stage pT1 tumors, 38 stage pT2 tumors, 24 stage pT3A tumors, four stage pT3B tumors and one stage Tx tumors. The therapeutic scheme consisted of pelvic radiation therapy (3 fractions of 3,5 Gy) immediately followed by lymphadenectomy (for stage pT3 tumors) and by cystotomy or partial cystectomy during which we inserted brachytherapy plastic tubes. The delivered dose was 50 Gy for superficially infiltrative tumors and 30 Gy for deeply infiltrative tumors; at the lowest dose, the treatment ended with external beam irradiation.At 5 years the control rate was 72%, the specific survival 80% and the global survival 71%. Twenty-nine patients had a local recurrence. Of these, seven underwent total cystectomy. Thirty-seven patients developed 43 complications; 35 were intravesical, 10 (28%) were estimated to be higher than grade 2 because of technical problems that led us to modify the technique.It is essential to develop close collaboration between surgeons and brachytherapists, to select patients and to use a rigorous technique. Interstitial brachytherapy for infiltrative vesical carcinomas thus yields both high local control and satisfying results in regard to patient's well-being.

The frequency of visits to an outpatients office is indicative of the proportion of population to be served at that location.Analysis of the frequency of new cases to an outpatients office over one year and correlation with the conditions treated over the corresponding period.To know the overall frequency of new cases, by condition, affected organ and group of diseases. To know the percentage of surgical resolution of those conditions. To infer from these data the resources necessary in terms of offices, operating theatres and staffThe outpatients office shows an overall frequency of new cases of 124/10000 people/year. The highest frequencies by condition, affected organ and group of diseases correspond to BPH, inguinoscrotal area and andrology. 35% of all new cases are managed surgically. 17.5% BPHs and 16.4% prostate carcinomas undergo surgery. The necessary resource are inferred to be: 1.5 ambulatory operating theatres/week, 2-2.5 central operating theatres/week. 5-6 office visits/week and 3 urologists.The study on the frequency of visits to the outpatients office is a useful tool for the organization and management of the Urology Service.

Metastatic involvement of the ureter due to renal parenchyma neoplasia has been reported in a total of 53 cases in the literature, the described mechanisms for tumoral spread being: haematogenic, lymphatic, canalicular and direct. Time to appearance of metastasis is far from prompting agreement among the authors in terms of its synchronous or metachronous nature. The most frequently reported symptoms are total and painless haematuria, and obstructive uropathy: CAT, percutaneous nephrostomy (for locally advanced disease) and endoscopy, are the most frequently used diagnostic tools. The only available therapy is nephrouretectomy for a diagnosis synchronous with the primitive tumour, and uretectomy for metachronous emergence. This paper reports on a case of sarcomatoid renal tumour with ipsilateral synchronous involvement of the ureter, which caused an obstructive uropathy treated by nephrouretectomy.

The Urology Unit at the Costa del Sol Hospital works in coordination with the primary health care network using diagnostic and therapeutic protocols.To know whether the system is effective based on the analysis of the quality of patient referral to Hospital according to the performance of family doctors.The referral document summarising the study conducted by the family doctor is analyzed. 578 correspond to conditions already coordinated and 269 to other situations not yet covered by the system.For the coordinated conditions, 29% referrals are high quality and 45.9% are poor. For non-coordinated conditions however, 9.2% are high quality and 57.7% poor. The difference is statistically significant (p0.001).Work in coordination with primary health care is feasible, effective and probably cost-efficient.

Primary prostatic carcinoma accounts for 2% to 4.5% of all neoplasias to this organ, and it has been observed in 2.8% of all radical cystoprostatectomies performed in the Mayo clinic. It originates in the poorly differentiated reservoir cells of the prostatic periurethral ductus which explains why diagnosis is most often obtained in advanced stages (stromal involvement), thus limiting its management to radical surgery. This paper contributes one case report of a patient diagnosed by transrectal biopsy of a primary prostatic transitional carcinoma presenting with incoercible rectorrahges and urinary obstruction symptoms. Treatment was through pelvic exenteration, and urinary and gut by-pass.

The study proposes the analysis of the influence of gross, microscopical and clinical pathoanatomical prognostic factors in the survival of patients with RCC through univariance and multivariance statistical analysis, and its global evaluation as a predictive model.The study involved 218 RCC cases operated on over 20 years, with a mean follow-up of 60 months.All prognostic factors studied have a significant influence on the survival. When studied jointly, they include separately and in order of significance the metastatic involvement, mitotic index, cava vein involvement, nuclear grade and sarcomatoid histologic pattern. Also, we confirm that considered jointly they conform a valid predictive model.

Polycystic disease of the adult is the most common presentation of renal cystic disease and is transmitted by dominant autosomic heredity. Development of renal cell carcinoma has been reported within this cystic disease, but the frequency of such coincidence is not higher than in the remaining population. Most of these tumours are found incidentally and may involve a diagnostic problem due to the marked distortion of the kidney's architecture produced by the polycystic disease of the adult.

Molluscum contagiosum is a skin lesion caused by a poxviridae virus. Infection in children takes place through cutaneous contact while in adults results from sexual contact or under immunosuppression conditions. In immunosuppressed patients this infection is caused by opportunistic microorganisms and, basically, its appears when CD4 levels reach a certain decline, therefore its presence can be considered as a marker for poor prognosis or advanced stage of the disease.

Maxwell’s electromagnetism equations and the old notions of Newtonian absolute time and Euclidian absolute space were contradictory with the impossibility of detection of the Earth’s absolute motion.

Earth rotation and the position of poles are essential elements of climate. Since centuries the motion of the poles with respect to the Earth’s surface has remained very small, but this was not necessarily the case during geological times. The orogeny of a large mountain range, such as Himalaya, modifies the Earth’s moments of inertia by a few millionths and this is sufficient for a large displacement of the stable equilibrium position of the poles; equilibrium position that is given by the main axis of largest inertia of the “non rotating Earth in isostatic equilibrium”. The corresponding motion of the poles remains usually very slow, as slow as the corresponding orogeny, and the Earth’s equatorial bulge doesn’t forbid the transformation. This bulge is only slowly deformed until its installation in the new position of equilibrium. The stable equilibrium positions depend very much on the variations of the Earth’s crust and the poles have certainly moved much more than the different lithospheric plates. Large orogenies and/or large subductions can move the poles by tens of degrees within a few million years.

Since 1987, we have treated four patients with diaphragma sellae meningioma. Tuberculum sellae meningiomas with intrasellar extension were strictly excluded from this retrospective study. A complete tumor removal was performed in two patients. The two other patients underwent post-operative radiotherapy. According to the Kinjo's classification, the four meningiomas were classified as follows: one type A (supradiaphragmatic-prepituitary), one type B (supradiaphragmatic-retropituitary), one type C (subdiaphragmatic), one type not described in this classification characterized by sub and supradiaphragmatic extension. Based on our experience and data in the literature, the clinical and neuroradiological features of the diaphragma sellae meningiomas are reviewed. Diaphragma sellae visualization at MRI, which is not always possible, allows to localize the tumor on a supra- or infra- diaphragmatic position and to decide the optimal surgical approach. The diaphragma sellae is more visible on protonic density, or T2-weighted sequences, but can be located on T1-weighted images. Appropriate surgical approaches are the sub-fronto-pterional route for supradiaphragmatic meningiomas and the transsphenoidal approach for subdiaphragmatic meningiomas.

Because of its high incidence and the high number of deaths induced, breast cancers in elderly women is a major health problem. The diagnosis is often clinical and the tumors are often at advanced stage with many initial metastases due to some neglect. Breast cancer in elderly women has no specific radiological form and is more often infiltrating ductal carcinoma of SBR grade I. Hormonal receptors are generally higher in elderly than in young women. Surgery of breast cancers with equal anesthetic risks factors does not induce more complications in elderly women than in the general population. In 12% of cases, an associated pathology influences the decision (degradation of the respiratory or cardiovascular function or reduction of the renal function). Between 70 and 80 years, provided that life expectancy is compatible with radiotherapy, corollary to conservative treatments in the present state of our knowledge for tumors under 3 to 4 cm, there is an alternative between radiosurgical conservative treatment and modified mastectomy associated with axillary dissection. In case of bulky tumors (3 to 4 cm) and failure of the hormonal treatment or impossibility to perform a complementary radiotherapy treatment (for instance, senile dementia), of axillary node involvement, a fortiori if the tumor has no hormonal receptors, the modified mastectomy with axillary dissection remains the therapeutic standard. In case of bulky tumor, the hormonal status can be used to induce the patient to accept an operation and, if necessary, to perform a conservative surgery. However, despite hormonosensitivity of breast cancer, a tumoral progression after a mean duration of hormonosensitivity of 25 months is to be expected in 93% of the cases, included 25% in whom a complete response to hormonotherapy was observed. A fractionated irradiation delivering 2 Gy per fraction and 5 fractions per week with a total number of sessions of 25 gives better esthetical results. This optimal treatment lasts 5 weeks and the patients often get tired since they are old and their radiotherapy centre is far from their house. Therefore hypofractionated treatment (once a week) should be proposed. The adjuvant medical treatment of reference for menopausal women is hormonotherapy by tamoxifen. Breast cancer in elderly women reduces life expectancy at 5 years by 50%; the theoretical therapeutic indications are the same as for young women, but their application is adapted to the patient. It would be dangerous and illusive to undertreat such a disease when the life expectancy is longer than 3 years.

Fungal urinary infections are becoming increasingly frequent as a result of widespread use of broad spectrum antibiotics, an increased number of immunocompromised patients and the greater longevity of chronic patients. Urinary tract infections by Toruplosis glabrata only come second in frequency after those caused by Candida albicans, accounting for 5 to 25% of all infections caused by fungi. The paper presents one case of pyonephrosis by Toruplosis glabrata in a female patient treated with fluconazole who later underwent nephrectomy. A description is made of the clinical picture, diagnosis and treatment of these infections.

Precapillary pulmonary hypertension was diagnosed in a 29 year old woman who became progressively more breathless (NYHA Class III) after her pregnancy, two years previously: systolic pulmonary artery pressure was 120 mmHg with an arterio-capillary pressure gradient of 30 mmHg. She had anti-nuclear autoantibodies detectable at 1/1000 and anti-DNA autoantibodies at 1/800 without any other manifestation of lupus. Treatment with prednisone (2 mg/kg/day) resulted in regression of her dyspnoea with a decrease of systolic pulmonary artery pressure to 65 mmHg, and of the arterio-capillary gradient to 15 mmHg; the lupus serology became negative with a clinical follow-up of 37 months. This observation shows that systemic lupus erythematosus may present with precapillary pulmonary hypertension, the conventional treatment of which may be successfully completed by steroid therapy.

The p53 protein, of the core protein group, was initially considered an oncogene but it was later noted to be included in the group of tumour-suppressive genes, the function of which seems to be focused in the control of cell growth, regulation of DNA transcription, and inhibition of certain oncogenes. A mutant protein variety has been observed with longer than normal mean life and altered function, so that it is not effective for the inhibitory control of cell growth. Mutations of that protein's gene, located in the short arm of chromosome 17, have been discovered in a large variety of tumours in humans, and in the urogenital region they have been consistently seen in both vesical and prostate tumours. The objective of the study was to confirm the need of this gene mutation, so that the vesical transitional cell tumour develops an infiltrant nature. The presence of mutations in this gene's exons 5 and 8 in infiltrant transitional cell tumours (28.5% cases) was demonstrated using as controls either surface transitional cell tumours, non-transitional tumours and healthy vesical tissue obtained together with the tumour specimen in each surgical procedure. The methods used were PCR (polymerase chain reaction) and the identification of the mutated specimen through TGGE (temperature gradient electrophoresis). The absence of mutations in the control strips together with the observation of mutations in the specimens from infiltrant tumours confirms the above hypothesis.

Various therapeutic strategies have been recently proposed to prevent the vasospasm after subarachnoid haemorrhage, and to avoid its clinical consequences. Despite these progresses, mortality and morbidity of delayed ischaemic consequences of vasospasm remain important. Two endovascular treatments have been proposed. The successful use of transluminal angioplasty for vasospasm was first reported by Zubkov in 1984. Transluminal angioplasty is very effective with clinical improvement when the treatment is undertaken without delay after the onset of symptoms. Limitations of this technique are the inaccessibility of distal arteries and the risks (vascular rupture or occlusion). More recently, to overcome these limitations, a selective intraarterial infusion of papaverine has been proposed. These infusions are less risky and can be employed in distal vasospasm. However, clinical results seem to be less favourable and often transient. These two techniques are still used with slightly different indications. According to our experience, it seems reasonable to reserve transluminal angioplasty for symptomatic vasospasm, associated with papaverine or not, and to use papaverine alone in all other cases.