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Long Term Results of Adjuvant and Salvage Radiotherapy after Radical Prostatectomy
Proceedings of the 51st Annual ASTRO Meeting Brachy 70-96 %, Cryo 83%, EBRT 52-82%, HIFU 54%, Proton 79%, and RP 60-63%. No Robot RP met criteria. Relaxing the criteria to.40 months median follow up or less than 100 pts did not affect overall results in either risk group. Conclusions: Brachytherapy, Cryotherapy, EBRT, Proton therapy and RP are effective treatments for low and intermediate risk prostate cancer in the majority of patients. The current literature largely fails to report results using minimum and comparable criteria. The large number of studies that fail to stratify patients preoperatively into risk groups or fail to meet a median follow up of 5 years represents a challenge to the oncology community to exact stricter criteria for reporting results which are meaningful, comparable and understandable to physicians, patients and interested parties. Author Disclosure: P.D. Grimm, Bard, Inc, F. Consultant/Advisory Board; Nexcura, Inc, F. Consultant/Advisory Board; Oncura, Inc, F. Consultant/Advisory Board; J.E. Sylvester, Oncura, F. Consultant/Advisory Board;. The Prostate Cancer Results Study, None.
2250
Potential Roles for Radiation and Other Bladder-sparing Approaches In Small Cell Carcinoma of the Bladder
E. J. Koay1, B. S. Teh2, A. C. Paulino2, E. B. Butler2 1 Baylor College of Medicine, Department of Radiology, Section of Radiation Oncology, Houston, TX, 2The Methodist Hospital, Department of Radiation Oncology, Houston, TX
Purpose/Objective(s): A large number of case reports and a limited number of retrospective studies have been published on small cell carcinoma of the bladder. Many treatment strategies have been attempted over two decades, but this rare cancer still remains poorly understood and carries a bad prognosis. Our objective was to better characterize this disease with the Surveillance and Epidemiology End Results (SEER) Database. Materials/Methods: We used the SEER Database to study small cell carcinoma of the bladder, aiming to delineate its epidemiology, understand its natural history, identify prognosticators, and investigate its treatment, particularly regarding bladder-sparing approaches. Results: There were 699 cases in the database, showing a significant increase in incidence from 1985 to 2005 from 0.02% to 0.6% of all bladder cancers (p \ 0.0001). Caucasian males were predominantly affected (10:1 ratio of Caucasian to non-Caucasian and 3:1 ratio of male to female) at advanced age (70.9±11.6 years), with most patients presenting with locally advanced or metastatic disease according to AJCC staging for bladder cancer (Stage I 14.8%, II 39.1%, III 16.5%, and IV 29.6%). Median survival was 11 months. Patient age was a significant predictor of survival (p\0.0001) as well as nodal status (p\0.0001). Comparison of overall survival according to SEER historical staging demonstrated a significant difference between localized compared to regional and distant disease (p \ 0.0001). Over two decades, there has been a significant trend (p = 0.02) toward treating patients with local surgical approaches alone, such as transurethral resection, fulguration, and cryosurgery. Currently, about 50% of patients receive only local surgical therapy. The use of radiation has remained stable between 10-20% for all patients. Overall survival has not significantly changed, despite these treatment trends. Interestingly, the patients who received radiation after local surgery had a significant overall survival advantage compared to local surgery alone (p \ 0.0001). Additionally, there was no difference in overall survival when comparing partial cystectomy with radical cystectomy. Conclusions: This study represents the largest analysis of this disease to our knowledge, providing new insights on important characteristics such as epidemiology, prognostic variables, and staging. In particular, the SEER historical staging result suggests that a simpler system akin to small cell lung cancer may be appropriate (i.e., limited vs. extensive stage). Moreover, the data shed new light on various treatment strategies and suggest roles for radiation and other bladder-sparing approaches. Author Disclosure: E.J. Koay, None; B.S. Teh, None; A.C. Paulino, None; E.B. Butler, None.
2251
Long Term Results of Adjuvant and Salvage Radiotherapy after Radical Prostatectomy
Y. Bolukbasi, L. B. Levy, A. Lee, S. Choi, R. M. Cheung, S. Frank, Q. Nguyen, D. A. Kuban M.D. Anderson Cancer Center, Houston, TX Purpose/Objective(s): To compare outcome with adjuvant (ART) vs. (SRT) salvage post-operative radiotherapy (RT). Materials/Methods: One-hundred thirty nine patients received ART and 202 patients SRT for rising PSA post- radical prostatectomy (RP) at the M. D. Anderson Cancer Center. Patients who received chemotherapy and/or androgen deprivation prior to RP were excluded. The median dose was 60 Gy (range: 54-70 Gy) for ART and 70 Gy (range: 62-74 Gy) for SRT. Twenty-two percent of the patients who received ART and 55% who received SRT were also treated with hormonal therapy (HT) in conjunction with RT. The median duration of HT was 12 months. The median PSA prior to RT was \0.1 ng/ml and 0.6 ng/ml for ART and SRT, respectively. A biochemical (PSA) failure after RT was defined as PSA $ 0.20 ng/ml and rising, or initiation of hormone therapy. PSA-disease-free survival (PSADFS) was calculated from the end of RT by the Kaplan-Meier method. The median follow-up was 6.3 years for all patients, 8.8 years for the ART patients and 5.1 years for the SRT patients. Results: For the ART group, the 5 and 10 year PSADFS rates were 84%, and 79%. Within this group, 5 and 10 year PSADFS for patients with undetectable PSA (#0.1 ng/ml) was significantly better than for patients with detectable PSA (90%/85% and 58%/ 48%, p \ .0001). The significant predictive factors for PSADFS in multivariate analysis were positive margins (HR: 0.14, p = .002), seminal vesicle involvement (HR: 5.72, p = .0003), pre-RT PSA .0.1 ng/ml (HR: 2.61, p = .036). No significant association was observed between adjuvant HT, the RP-Gleason score, Pre-RP PSA level, length of HT, or the presence of extracapsuler extension and the PSADF status. For the SRT group, the 5 and 10 year PSADFS rates were 71% and 68% and significantly less than the PSADFS for the ART group (p = .014). In regression analysis, a pre-RT PSA of #0.5 ng/ml and positive margins defined a favorable subgroup with 5 and 10 year PSADFS of 87% and 80% as compared to 64% and 62% for unfavorable patients (p = .001). For SRT patients in the unfavorable subgroup, HT improved PSADFS at 5 years from 43% to 77%, and at 10 years from 43% to 74%, p \ .0001. For patients in the favorable subgroup, the improvement in PSADFS survival was not as great, 82% vs. 93% and 77% vs. 84% at 5 and 10 years, p = .70. When comparing the outcome between ART and SRT, a decrease in PSADFS become evident in the SRT group at a Pre-RT-PSA level of 0.5 ng/ml. This difference became statistically significant at a pre-RT PSA level of 0.7 ng/ml where corresponding 5 and 10 year PSADFS was 84%/ 79% for ART and 74%/ 70% for SRT, p = .03.
S293
I. J. Radiation Oncology d Biology d Physics
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Volume 75, Number 3, Supplement, 2009
Conclusions: In retrospective analysis, PSADFS with SRT appears similar to that with ART when pre-RT PSA levels are # 0.5 ng/ ml. HT improved outcome in patients in the unfavorable SRT subgroup. Author Disclosure: Y. Bolukbasi, None; L.B. Levy, None; A. Lee, None; S. Choi, None; R.M. Cheung, None; S. Frank, None; Q. Nguyen, None; D.A. Kuban, Calypso Medical Scientific Advisory Board, F. Consultant/Advisory Board.
2252
Real-time Position Adjustment during Treatment for Localized Prostate Cancers: Observations on Clinical Use and Acute Toxicity
K. M. Langen, A. P. Shah, T. R. Willoughby, S. L. Meeks, P. A. Kupelian M.D. Anderson Cancer Center Orlando, Orlando, FL Purpose/Objective(s): To report on the clinical use of 4D real-time tracking of the prostate gland and acute toxicity observations comparing patients with real-time position correction. Materials/Methods: The CalypsoÒ System was utilized in 51 patients treated with 40 fractions, total dose 80 Gy, 3 mm posterior planning margins, 5 mm otherwise. A 3 mm threshold was used to trigger position corrections; the therapists were instructed to re-adjust the position if the prostate drift persisted .3 mm. If the motion was transient, even if .3 mm, the instructions were not to intervene. In addition, instruction was given not to interrupt individual beam deliveries and adjust only in between beams. Each session was categorized as follows: Group 0 - motion within 3 mm (not requiring correction), Group 1 - motion exceeding 3 mm not requiring correction (mostly transient motion), Group 2 - motion exceeding 3 mm requiring correction, and Group 3 - any motion where the course of action was determined differently by the therapists versus the physician. Acute rectal and urinary RTOG toxicity rates were reported. Particular attention was given to patients with high pretreatment AUA symptom scores (.15). Results: For the 51 cases, the analysis was performed on 1997 of a total 2040 sessions (98%); an average of 39.2 fractions per patient (range 32-40). Of all 1997 fractions, 1273 (64%) were in Group 0, 202 (10%) were in Group 1, 514 (25%) were in Group 2 (individual patient range: 10-100%), and only 8 (0.7%) were in Group 3. In Group 1 (n = 202), the reason for no correction was either the motion being transient or close to 3 mm. In individual patients, the frequency of corrections ranged from 0 to 31%. Of all 514 fractions in Group 2, realignment was performed once throughout the session in 432 (21% of all fractions, individual patient range 0 to 65%), twice in 73 (4% of all fractions, individual patient range 0 to 43%), and three times in 9 (0.5% of all fractions, individual patient range 0 to 13%). Finally, therapist disagreement with the physician was rare (\1%, individual patient range 0 to 5%), typically when the physician would have re-adjusted the patient’s position whereas the therapists did not intervene. Overall, only 4% developed grade 2 acute rectal toxicity. The grade 2 acute urinary toxicity rate was 27%. In the subset of patients with initial AUA scores .15, the grade 2 acute urinary toxicity rate was only 29%. Conclusions: Using a 3 mm action threshold, intrafraction position corrections were performed in 25% of all fractions, with large individual variations. The acute toxicity profile was favorable, particularly in patients with unfavorable pretreatment urinary function. Further follow-up is required to assess the impact of intrafraction position adjustment on local control and late toxicity. Author Disclosure: K.M. Langen, Calypso Medical, C. Other Research Support; A.P. Shah, Calypso Medical, C. Other Research Support; T.R. Willoughby, None; S.L. Meeks, Calypso Medical, C. Other Research Support; P.A. Kupelian, Calypso Medical, C. Other Research Support.
2253
Management of Testicular Seminoma in France and Compliance with National Guidelines
1
N. Mottet , S. Hoppe2, C. Hennequin3, S. Culine4, M. Saves5,6 Clinique Mutualiste, St Etienne, France, 2Registre des Cancers de la Gironde, Bordeaux, France, 3CHU St Louis, Paris, France, 4CHU Henri Mondor, Creteil, France, 5Registre des Cancers de la Gironde, Bordeaux, France, 6Pole Sante´ Publique, CHU Bordeaux, France 1
Purpose/Objective(s): Our aim is to describe the management of primary testicular Seminoma (TS) in France and to evaluate compliance with the national guidelines. In the event of non-compliance, factors associated will be investigated. Materials/Methods: Cases of TS diagnosed in 2003-2004 were identified from eleven general official exhaustive cancer registries. A detailed medical chart was used to collect individual data on tumor description and management. National guidelines published in 2002 were used as reference (Progre`s en Urologie 2002;12:71-78). A conformity list was defined by a group of experts. Each criterion could be in accordance with the recommendations, severely non-compliant (disagreement with the recommendations with a potential impact on outcome), marginally non-compliant (no effect on patient outcome) and non-compliant but justifiable (noncompliance explained by patient or tumor characteristics). Management was evaluated by step, then globally. Factors associated with non-compliance (severe non-conformity vs. other) were identified using a marginal logistic model to take into account correlation between observations within same residence department. Results: 256 patients with TS were included: 76% had a stage I, 17% a stage II, 7% a stage III and 9% an undetermined one. Globally only 6% of patients received a totally conform management (all stages combined). When restricting to therapeutic steps only (orchiectomy, treatment and follow-up), conformity to standard guideline was approximately 44% only. The severe non-conformity rates for tumor markers performed at diagnosis, histology report, radiotherapy and chemotherapy were: 39.8%, 64.5%, 30.7% and 61.5% respectively. In multivariate analysis, therapeutic steps non-compliance were more frequent in more advanced stage (Odds ratio (OR) = 2.13 [95% CI: 1.06-4.29). Non-compliance was less common in case of multidisciplinary discussion (OR = 0.41 [0.18-0.91]), and when orchiectomy was performed in a teaching hospital, in a comprehensive cancer center or in private practice, compared to a general hospital: OR = 0.27 [0.08-0.88] and OR = 0.22 [0.08-0.63] respectively, teaching hospital and comprehensive cancer center or private practice taking care of more patients (18% and 69% respectively vs. 13% in general hospital). Conclusions: Based on exhaustive French cancer registries (covering 13% of the metropolitan population) the real life TS management is quite disappointing. The low incidence of stage II and III might explain the high non-conformity rate with the
2250
Potential Roles for Radiation and Other Bladder-sparing Approaches In Small Cell Carcinoma of the Bladder
E. J. Koay1, B. S. Teh2, A. C. Paulino2, E. B. Butler2 1 Baylor College of Medicine, Department of Radiology, Section of Radiation Oncology, Houston, TX, 2The Methodist Hospital, Department of Radiation Oncology, Houston, TX
Purpose/Objective(s): A large number of case reports and a limited number of retrospective studies have been published on small cell carcinoma of the bladder. Many treatment strategies have been attempted over two decades, but this rare cancer still remains poorly understood and carries a bad prognosis. Our objective was to better characterize this disease with the Surveillance and Epidemiology End Results (SEER) Database. Materials/Methods: We used the SEER Database to study small cell carcinoma of the bladder, aiming to delineate its epidemiology, understand its natural history, identify prognosticators, and investigate its treatment, particularly regarding bladder-sparing approaches. Results: There were 699 cases in the database, showing a significant increase in incidence from 1985 to 2005 from 0.02% to 0.6% of all bladder cancers (p \ 0.0001). Caucasian males were predominantly affected (10:1 ratio of Caucasian to non-Caucasian and 3:1 ratio of male to female) at advanced age (70.9±11.6 years), with most patients presenting with locally advanced or metastatic disease according to AJCC staging for bladder cancer (Stage I 14.8%, II 39.1%, III 16.5%, and IV 29.6%). Median survival was 11 months. Patient age was a significant predictor of survival (p\0.0001) as well as nodal status (p\0.0001). Comparison of overall survival according to SEER historical staging demonstrated a significant difference between localized compared to regional and distant disease (p \ 0.0001). Over two decades, there has been a significant trend (p = 0.02) toward treating patients with local surgical approaches alone, such as transurethral resection, fulguration, and cryosurgery. Currently, about 50% of patients receive only local surgical therapy. The use of radiation has remained stable between 10-20% for all patients. Overall survival has not significantly changed, despite these treatment trends. Interestingly, the patients who received radiation after local surgery had a significant overall survival advantage compared to local surgery alone (p \ 0.0001). Additionally, there was no difference in overall survival when comparing partial cystectomy with radical cystectomy. Conclusions: This study represents the largest analysis of this disease to our knowledge, providing new insights on important characteristics such as epidemiology, prognostic variables, and staging. In particular, the SEER historical staging result suggests that a simpler system akin to small cell lung cancer may be appropriate (i.e., limited vs. extensive stage). Moreover, the data shed new light on various treatment strategies and suggest roles for radiation and other bladder-sparing approaches. Author Disclosure: E.J. Koay, None; B.S. Teh, None; A.C. Paulino, None; E.B. Butler, None.
2251
Long Term Results of Adjuvant and Salvage Radiotherapy after Radical Prostatectomy
Y. Bolukbasi, L. B. Levy, A. Lee, S. Choi, R. M. Cheung, S. Frank, Q. Nguyen, D. A. Kuban M.D. Anderson Cancer Center, Houston, TX Purpose/Objective(s): To compare outcome with adjuvant (ART) vs. (SRT) salvage post-operative radiotherapy (RT). Materials/Methods: One-hundred thirty nine patients received ART and 202 patients SRT for rising PSA post- radical prostatectomy (RP) at the M. D. Anderson Cancer Center. Patients who received chemotherapy and/or androgen deprivation prior to RP were excluded. The median dose was 60 Gy (range: 54-70 Gy) for ART and 70 Gy (range: 62-74 Gy) for SRT. Twenty-two percent of the patients who received ART and 55% who received SRT were also treated with hormonal therapy (HT) in conjunction with RT. The median duration of HT was 12 months. The median PSA prior to RT was \0.1 ng/ml and 0.6 ng/ml for ART and SRT, respectively. A biochemical (PSA) failure after RT was defined as PSA $ 0.20 ng/ml and rising, or initiation of hormone therapy. PSA-disease-free survival (PSADFS) was calculated from the end of RT by the Kaplan-Meier method. The median follow-up was 6.3 years for all patients, 8.8 years for the ART patients and 5.1 years for the SRT patients. Results: For the ART group, the 5 and 10 year PSADFS rates were 84%, and 79%. Within this group, 5 and 10 year PSADFS for patients with undetectable PSA (#0.1 ng/ml) was significantly better than for patients with detectable PSA (90%/85% and 58%/ 48%, p \ .0001). The significant predictive factors for PSADFS in multivariate analysis were positive margins (HR: 0.14, p = .002), seminal vesicle involvement (HR: 5.72, p = .0003), pre-RT PSA .0.1 ng/ml (HR: 2.61, p = .036). No significant association was observed between adjuvant HT, the RP-Gleason score, Pre-RP PSA level, length of HT, or the presence of extracapsuler extension and the PSADF status. For the SRT group, the 5 and 10 year PSADFS rates were 71% and 68% and significantly less than the PSADFS for the ART group (p = .014). In regression analysis, a pre-RT PSA of #0.5 ng/ml and positive margins defined a favorable subgroup with 5 and 10 year PSADFS of 87% and 80% as compared to 64% and 62% for unfavorable patients (p = .001). For SRT patients in the unfavorable subgroup, HT improved PSADFS at 5 years from 43% to 77%, and at 10 years from 43% to 74%, p \ .0001. For patients in the favorable subgroup, the improvement in PSADFS survival was not as great, 82% vs. 93% and 77% vs. 84% at 5 and 10 years, p = .70. When comparing the outcome between ART and SRT, a decrease in PSADFS become evident in the SRT group at a Pre-RT-PSA level of 0.5 ng/ml. This difference became statistically significant at a pre-RT PSA level of 0.7 ng/ml where corresponding 5 and 10 year PSADFS was 84%/ 79% for ART and 74%/ 70% for SRT, p = .03.
S293
I. J. Radiation Oncology d Biology d Physics
S294
Volume 75, Number 3, Supplement, 2009
Conclusions: In retrospective analysis, PSADFS with SRT appears similar to that with ART when pre-RT PSA levels are # 0.5 ng/ ml. HT improved outcome in patients in the unfavorable SRT subgroup. Author Disclosure: Y. Bolukbasi, None; L.B. Levy, None; A. Lee, None; S. Choi, None; R.M. Cheung, None; S. Frank, None; Q. Nguyen, None; D.A. Kuban, Calypso Medical Scientific Advisory Board, F. Consultant/Advisory Board.
2252
Real-time Position Adjustment during Treatment for Localized Prostate Cancers: Observations on Clinical Use and Acute Toxicity
K. M. Langen, A. P. Shah, T. R. Willoughby, S. L. Meeks, P. A. Kupelian M.D. Anderson Cancer Center Orlando, Orlando, FL Purpose/Objective(s): To report on the clinical use of 4D real-time tracking of the prostate gland and acute toxicity observations comparing patients with real-time position correction. Materials/Methods: The CalypsoÒ System was utilized in 51 patients treated with 40 fractions, total dose 80 Gy, 3 mm posterior planning margins, 5 mm otherwise. A 3 mm threshold was used to trigger position corrections; the therapists were instructed to re-adjust the position if the prostate drift persisted .3 mm. If the motion was transient, even if .3 mm, the instructions were not to intervene. In addition, instruction was given not to interrupt individual beam deliveries and adjust only in between beams. Each session was categorized as follows: Group 0 - motion within 3 mm (not requiring correction), Group 1 - motion exceeding 3 mm not requiring correction (mostly transient motion), Group 2 - motion exceeding 3 mm requiring correction, and Group 3 - any motion where the course of action was determined differently by the therapists versus the physician. Acute rectal and urinary RTOG toxicity rates were reported. Particular attention was given to patients with high pretreatment AUA symptom scores (.15). Results: For the 51 cases, the analysis was performed on 1997 of a total 2040 sessions (98%); an average of 39.2 fractions per patient (range 32-40). Of all 1997 fractions, 1273 (64%) were in Group 0, 202 (10%) were in Group 1, 514 (25%) were in Group 2 (individual patient range: 10-100%), and only 8 (0.7%) were in Group 3. In Group 1 (n = 202), the reason for no correction was either the motion being transient or close to 3 mm. In individual patients, the frequency of corrections ranged from 0 to 31%. Of all 514 fractions in Group 2, realignment was performed once throughout the session in 432 (21% of all fractions, individual patient range 0 to 65%), twice in 73 (4% of all fractions, individual patient range 0 to 43%), and three times in 9 (0.5% of all fractions, individual patient range 0 to 13%). Finally, therapist disagreement with the physician was rare (\1%, individual patient range 0 to 5%), typically when the physician would have re-adjusted the patient’s position whereas the therapists did not intervene. Overall, only 4% developed grade 2 acute rectal toxicity. The grade 2 acute urinary toxicity rate was 27%. In the subset of patients with initial AUA scores .15, the grade 2 acute urinary toxicity rate was only 29%. Conclusions: Using a 3 mm action threshold, intrafraction position corrections were performed in 25% of all fractions, with large individual variations. The acute toxicity profile was favorable, particularly in patients with unfavorable pretreatment urinary function. Further follow-up is required to assess the impact of intrafraction position adjustment on local control and late toxicity. Author Disclosure: K.M. Langen, Calypso Medical, C. Other Research Support; A.P. Shah, Calypso Medical, C. Other Research Support; T.R. Willoughby, None; S.L. Meeks, Calypso Medical, C. Other Research Support; P.A. Kupelian, Calypso Medical, C. Other Research Support.
2253
Management of Testicular Seminoma in France and Compliance with National Guidelines
1
N. Mottet , S. Hoppe2, C. Hennequin3, S. Culine4, M. Saves5,6 Clinique Mutualiste, St Etienne, France, 2Registre des Cancers de la Gironde, Bordeaux, France, 3CHU St Louis, Paris, France, 4CHU Henri Mondor, Creteil, France, 5Registre des Cancers de la Gironde, Bordeaux, France, 6Pole Sante´ Publique, CHU Bordeaux, France 1
Purpose/Objective(s): Our aim is to describe the management of primary testicular Seminoma (TS) in France and to evaluate compliance with the national guidelines. In the event of non-compliance, factors associated will be investigated. Materials/Methods: Cases of TS diagnosed in 2003-2004 were identified from eleven general official exhaustive cancer registries. A detailed medical chart was used to collect individual data on tumor description and management. National guidelines published in 2002 were used as reference (Progre`s en Urologie 2002;12:71-78). A conformity list was defined by a group of experts. Each criterion could be in accordance with the recommendations, severely non-compliant (disagreement with the recommendations with a potential impact on outcome), marginally non-compliant (no effect on patient outcome) and non-compliant but justifiable (noncompliance explained by patient or tumor characteristics). Management was evaluated by step, then globally. Factors associated with non-compliance (severe non-conformity vs. other) were identified using a marginal logistic model to take into account correlation between observations within same residence department. Results: 256 patients with TS were included: 76% had a stage I, 17% a stage II, 7% a stage III and 9% an undetermined one. Globally only 6% of patients received a totally conform management (all stages combined). When restricting to therapeutic steps only (orchiectomy, treatment and follow-up), conformity to standard guideline was approximately 44% only. The severe non-conformity rates for tumor markers performed at diagnosis, histology report, radiotherapy and chemotherapy were: 39.8%, 64.5%, 30.7% and 61.5% respectively. In multivariate analysis, therapeutic steps non-compliance were more frequent in more advanced stage (Odds ratio (OR) = 2.13 [95% CI: 1.06-4.29). Non-compliance was less common in case of multidisciplinary discussion (OR = 0.41 [0.18-0.91]), and when orchiectomy was performed in a teaching hospital, in a comprehensive cancer center or in private practice, compared to a general hospital: OR = 0.27 [0.08-0.88] and OR = 0.22 [0.08-0.63] respectively, teaching hospital and comprehensive cancer center or private practice taking care of more patients (18% and 69% respectively vs. 13% in general hospital). Conclusions: Based on exhaustive French cancer registries (covering 13% of the metropolitan population) the real life TS management is quite disappointing. The low incidence of stage II and III might explain the high non-conformity rate with the