32 Paediatric Malignancies

626 Paediatric Malignancies

treated for recurrence, there was one nodal recurrence. 13/19 patients are alive after a mean follow- up of 12 years. Among the causes of death, 4 were due to nodal progression and 2 to metastatic disease. Significant cosmetic side effects in the soft tissues of the face (Fig 31.9A-B (same patient as in Fig 31.1A-B); Fig 31.10A-D) and bone have been observed in 4 children requiring cosmetic surgery. (1,18) Trunk and Limbs: The results of soft tissue sarcomas of the trunk and limbs were the worst observed in the Gustave Roussy series when compared to those obtained in other tumour sites. The 3 year survival rate was 68%, the local failure rate 31% ± metastases 50%. (13,16,18) The Institut Gustave-Roussy results are comparable to those published by other groups. Fontanesi et al (7) report about 48 children treated at St. Jude Hospital with 62 LDR implants: at 5 years disease- free survival was 75%, local control rate 86%, complication rate 26%. All other series report small patient numbers, but similar results. For PDR and HDR brachytherapy there is very limited experience reported in the literature. Nag et al. (29) and Pötter et al. (31) report on small patient numbers at different sites (head and neck, pelvis, trunk, limbs) with local control in 11/13 and 9/12. As follow-up is short, no data on late side effects are given. Clear-cell adenocarcinoma: The largest number of patients were treated at the IGR. (12,15,16,17) In this series of fifty patients who underwent brachytherapy (cervix 28%, vagina 25%, combined 47%) there were 20% in FIGO stage I, 40% in stage II, 25% in stage III, 15% in stage IV and overall 32% with positive pelvic nodes. The 2-year survival rate was 83 - 95% for stage I and II, 57% for stage III and IV, 90% for those with negative nodes and 50% for those with positive nodes. Complete conservative organ sparing treatment was achieved in 70% and each of two patients gave birth to a healthy child (Fig 9). (15,16) 11.2 Adverse side effects The problem of tolerance, early reactions, late effects and complications in children irradiated for cancer, constitutes a crucial point. As was said before, the normal tissue of a child is very radiosensitive, and the radiation morbidity is correlated to the age of the patient, to the delivered dose and to the irradiated volume. It is difficult to analyze the complications induced by different therapeutic strategies, particularly in a multidisciplinary approach and therefore to define the specific role of brachytherapy. Since few publications reported in detail the complications and the different grading systems used, a retrospective study is even more difficult. Complication rates, including definitive late sequelae grade 2 and 3, range from 20 to 30%. This range is high, but must be compared to the complication rates after EBRT or from radical, non conservative surgery. In conclusion, it is encouraging to note that girls treated for cancer in childhood are able to give birth to a child when they are adult. Among the patients treated for gynaecological tumours by a multidisciplinary approach in the IGR series, 5 children were born during the last decades. The first healthy birth of a child to a woman previously treated for a clear cell adenocarcinoma by conservative surgery and brachytherapy at the IGR was in 1992. The determination of the GTV with the support of modern imaging, the technical progress of brachytherapy, the advances in chemotherapy and in conservative surgery, and the expertise of some dedicated groups makes it possible for brachytherapy to play an important role in the