Radiotherapy of salivary gland tumours

Primary tumours of the salivary glands account for about 5 to 10% of tumours of the head and neck. These tumours represent a multitude of situations and histologies, where surgery is the mainstay of treatment and radiotherapy is frequently needed for malignant tumours (in case of stage T3-T4, nodal involvement, extraparotid invasion, positive or close resection margins, histological high-grade tumour, lymphovascular or perineural invasion, bone involvement postoperatively, or unresectable tumours). The diagnosis relies on anatomic and functional MRI and ultrasound-guided fine-needle aspiration for the diagnostic of benign or malignant tumors. In addition to patient characteristics, the determination of primary and nodal target volumes depends on tumor extensions and stage, histology and grade. Therefore, radiotherapy of salivary gland tumors requires a certain degree of personalization, which has been codified in the recommendations of the French multidisciplinary network of expertise for rare ENT cancers (Refcor) and may justify a specialised multidisciplinary discussion. Although radiotherapy is usually recommended for malignant tumours only, recurrent pleomorphic adenomas may sometimes require radiotherapy based on multidisciplinary discussion. An update of indications and recommendations for radiotherapy for salivary gland tumours in terms of techniques, doses, target volumes and dose constraints to organs at risk of the French society for radiotherapy and oncology (SFRO) was reported in this article.

Tracheal necrosis following thyroid radiofrequency ablation

INTRODUCTION

Radiofrequency ablation for benign thyroid nodules has a low rate of complications in experienced hands for selected indications, but tracheal necrosis is a major complication.

CASE REPORT

A 60 year-old female patient underwent percutaneous radiofrequency ablation of an unesthetic benign isthmic thyroid nodule. The procedure was performed with a cooled electrode, using the "moving shot" technique on a trans-isthmic approach, under general anesthesia. Postoperative course was complicated by dysphonia and cervical pain implicating a third-degree skin burn of the medial cervical region progressing to severe soft-tissue and cervical tracheal necrosis.

DISCUSSION

Risk factors in the present case included the general anesthesia, isthmic location and thyroid nodule volume. To avoid this kind of complication, the procedure should be performed under local anesthesia, using cooled dextrose solution hydrodissection between trachea, thyroid and skin. Ahead of radiofrequency ablation, patients should be informed of possible major complications, especially if the indication is cosmetic.

[Non-targeted effects (bystander, abscopal) of external beam radiation therapy: an overview for the clinician]

Radiotherapy is advocated in the treatment of cancer of over 50 % of patients. It has long been considered as a focal treatment only. However, the observation of effects, such as fatigue and lymphopenia, suggests that systemic effects may also occur. The description of bystander and abscopal effects suggests that irradiated cells may exert an action on nearby or distant unirradiated cells, respectively. A third type of effect that involves feedback interactions between irradiated cells was more recently described (cohort effect). This new field of radiation therapy is yet poorly understood and the definitions suffer from a lack of reproducibility in part due to the variety of experimental models. The bystander effect might induce genomic instability in non-irradiated cells and is thus extensively studied for a potential risk of radiation-induced cancer. From a therapeutic perspective, reproducing an abscopal effect by using a synergy between ionizing radiation and immunomodulatory agents to elicit or boost anticancer immune responses is an interesting area of research. Many applications are being developed in particular in the field of hypofractionated stereotactic irradiation of metastatic disease.

[Radiation therapy for pleomorphic adenoma of the parotid]

Parotid pleomorphic adenoma is the most frequent tumor of salivary glands. The prognosis depends on the recurrences because they could lead to iatrogenic events (facial paralysis). Moreover the risk of malignant transformation increases with the number of local relapses. This article aims at reviewing histological and radiological criteria and the surgical techniques. To improve local control, adjuvant irradiation (in first intention or after recurrence) may be useful but is still controversial for benign tumors in young patients with a risk of radio-induced cancer. We listed studies in which adjuvant radiotherapy was used so as to define its place in the treatment strategy. Prognostic factors were found by some authors. Other studies have to be done before strong evidence-based recommendations are issued.

[Target volumes in cervical lympadenopathies of unknown primary: toward a selective customized approach? On behalf of REFCOR]

The treatment of carcinomas of unknown primary revealed by cervical lymphadenopathy is based on neck dissection and nodal and pan-mucosal irradiation to control the neck and avoid the emergence of a metachronous primary. The aim of this review was to assess diagnostic and therapeutic approaches and criteria that may be used for a customized selective approach to avoid severe toxicities of pan-mucosal irradiation. A literature search was performed with the following keywords: cervical lymphadenopathy, unknown primary, upper aerodigestive tract, cancer, radiotherapy, squamous cell carcinoma, variants. The diagnostic workup includes a head and neck scanner or MRI, ((18)F)-FDG PET CT, a panendoscopy and tonsillectomy. Squamous cell carcinoma represents over two thirds of cases. The number of metastatic cervical nodes, nodal level, and histological variant (associated with HPV/EBV status) may determine the primary site origin and might be weighted for the determination of radiation target volumes on a multidisciplinary basis. A selective customized approach is relevant to decrease radiation toxicity only if neck and mucosal control is not impaired. Although no recommendation can yet be made in the absence of sufficient level of evidence, the relevance of systematic pan-mucosal irradiation appears questionable in a number of clinical situations. Accordingly, a customized selective redefinition of target volumes may be discussed and be prospectively evaluated in relation to the therapeutic index obtained.

Diagnosis and treatment of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: An overview

Hereditary hemorrhagic telangiectasia (HHT) or Rendu-Osler-Weber disease is an autosomic dominant disorder, which is characterized by the development of multiple arteriovenous malformations in either the skin, mucous membranes, and/or visceral organs. Pulmonary arteriovenous malformations (PAVMs) may either rupture, and lead to life-threatening hemoptysis/hemothorax or be responsible for a right-to-left shunting leading to paradoxical embolism, causing stroke or cerebral abscess. PAVMs patients should systematically be screened as the spontaneous complication rate is high, by reaching almost 50%. Neurological complications rate is considerably higher in patients presenting with diffuse pulmonary involvement. PAVM diagnosis is mainly based upon transthoracic contrast echocardiography and CT scanner examination. The latter also allows the planification of treatments to adopt, which consists of percutaneous embolization, having replaced surgery in most of the cases. The anchor technique consists of percutaneous coil embolization of the afferent pulmonary arteries of the PAVM, by firstly placing a coil into a small afferent arterial branch closely upstream the PAVM. Enhanced contrast CT scanner is the key follow-up examination that depicts the PAVM enlargement, indicating the various mechanisms of PAVM reperfusion. When performed by experienced operators as the prime treatment, percutaneous embolization of PAVMs, is a safe, efficient and sustained therapy in the great majority of HHT patients.

Clinical and histological prognostic factors in locally advanced oral cavity cancers treated with primary surgery

OBJECTIVE

The primary objective of this study was to determine the clinical and pathological prognostic factors in locally advanced oral cavity cancers treated by primary surgery.

METHODS

All patients treated by primary surgery with free-flap reconstruction for locally advanced oral cavity squamous cell carcinoma in our institution between 2000 and 2010 were included in this retrospective study. Overall, cause-specific and locoregional disease-free survivals were determined by Kaplan-Meier analyses. Clinical and histological prognostic factors were assessed by univariate (Log Rank tests) and multivariate (Cox models) analyses.

RESULTS

A total of 149 patients (102 men and 47 women; mean age=61.3±12.1 years) were included in the study. Five-year overall, cause-specific and locoregional disease-free survivals were 55%, 68% and 71%, respectively. Age, comorbidity and tumour size (histological evaluation) were significantly correlated with overall survival (P<0.05). Age, tumour size, bone invasion and surgical margins were significantly correlated with locoregional disease-free survival (P<0.05).

CONCLUSION

The main prognostic factors identified in this study were clinical (age and comorbidity) and histological (pathological tumour size, bone invasion and surgical margins).

Prognostic impact of tumour multifocality in thyroid papillary microcarcinoma based on a series of 160 cases

OBJECTIVE

The objective of this study was to evaluate the prognostic impact of tumour multifocality in papillary thyroid microcarcinoma (PTMC).

METHODS

All patients who underwent total thyroidectomy and central neck dissection for PTMC in our institution between 1990 and 2007 were included in this retrospective study. Statistical correlations between tumour multifocality and various clinical or pathological prognostic parameters were assessed by univariate and multivariate analyses.

RESULTS

A total of 160 patients (133 women and 27 men; mean age: 47.8±13.7 years) were included in this study. Tumour multifocality was demonstrated in 59 (37%) patients. Central neck metastatic lymph node involvement was identified in 46 (28%) patients. No statistical correlation was demonstrated between tumour multifocality and the following factors: age, gender, tumour size, extension beyond the thyroid, metastatic central neck lymph node involvement and risk of recurrence. A tumour diameter greater than 5mm was associated with a higher risk of recurrence (P=0.008).

CONCLUSION

Tumour multifocality does not appear to have a prognostic impact in PTMC.

Imaging of intervertebral disc prostheses

Disc arthroplasty is the replacement of a painful pathological intervertebral disc by a prosthesis, which, unlike spinal fixation, has the advantage of retaining vertebral mobility in the segment concerned. The success of the procedure is dictated by the indication. The radiologist must look for radiographic arguments indicating or contraindicating fitting an implant, and particularly for the presence of facet arthritis which will prompt the surgeon to choose an arthrodesis. Moreover, radiological information plays a major part in preparing for a surgical procedure, as far as access to the disc via the anterior approach is concerned and assessment by CT angiography of the risk of vascular complications. After insertion, radiological monitoring using dynamic X-ray images checks that the implant is correctly positioned and that mobility is restored. In the long term, it can detect complications related to the prosthesis and premature wear to other points of support such as adjacent discs and the facet joints.

[Revisiting the dose-effect correlations in irradiated head and neck cancer using automatic segmentation tools of the dental structures, mandible and maxilla]

PURPOSE

Manual delineation of dental structures is too time-consuming to be feasible in routine practice. Information on dose risk levels is crucial for dentists following irradiation of the head and neck to avoid postextraction osteoradionecrosis based on empirical dose-effects data established on bidimensional radiation therapy plans.

MATERIAL AND METHODS

We present an automatic atlas-based segmentation framework of the dental structures, called Dentalmaps, constructed from a patient image-segmentation database.

RESULTS

This framework is accurate (within 2 Gy accuracy) and relevant for the routine use. It has the potential to guide dental care in the context of new irradiation techniques.

CONCLUSION

This tool provides a user-friendly interface for dentists and radiation oncologists in the context of irradiated head and neck cancer patients. It will likely improve the knowledge of dose-effect correlations for dental complications and osteoradionecrosis.

[Posterior percutaneous arthrodesis under CT guidance after surgical anterior arthrodesis: a new technique]

Transfacet screws may be useful for stabilizing segments reconstructed with bone graft or cages, the role of supplementary posterior fixation, particularly minimally invasive techniques such as transfacetar percutaneous screws is relevant. To benefit from a mechanical fixation after anterior arthrodesis without the inconveniences of the open classical posterior surgical intervention, we have developed a new procedure performed under local anesthesia and CT guidance and based on the intra-articular application of screws. This study was designed to demonstrate the feasibility of using a CT-scan to perform posterior arthrodesis of the spine under local anesthesia.

[Pacemaker, implanted cardiac defibrillator and irradiation: Management proposal in 2010 depending on the type of cardiac stimulator and prognosis and location of cancer]

Ionizing radiation may interfere with electric components of pacemakers or implantable cardioverter-defibrillators. The type, severity and extent of radiation damage to pacemakers, have previously been shown to depend on the total dose and dose rate. Over 300,000 new cancer cases are treated yearly in France, among which 60% are irradiated in the course of their disease. One among 400 of these patients has an implanted pacemaker or defibrillator. The incidence of pacemaker and implanted cardioverter defribillator increases in an ageing population. The oncologic prognosis must be weighted against the cardiologic prognosis in a multidisciplinary and transversal setting. Innovative irradiation techniques and technological sophistications of pacemakers and implantable cardioverter-defibrillators (with the introduction of more radiosensitive complementary metal-oxide-semiconductors since 1970) have potentially changed the tolerance profiles. This review of the literature studied the geometric, dosimetric and radiobiological characteristics of the radiation beams for high energy photons, stereotactic irradiation, protontherapy. Standardized protocols and radiotherapy optimization (particle, treatment fields, energy) are advisable in order to improve patient management during radiotherapy and prolonged monitoring is necessary following radiation therapy. The dose received at the pacemaker/heart should be calculated. The threshold for the cumulated dose to the pacemaker/implantable cardioverter-defibrillator (2 to 5 Gy depending on the brand), the necessity to remove/displace the device based on the dose-volume histogram on dosimetry, as well as the use of lead shielding and magnet are discussed.

Basaloid squamous cell carcinoma of the head and neck: role of HPV and implication in treatment and prognosis

Basaloid squamous cell carcinoma (BSCC) is a rare variant of squamous cell carcinoma (SCC) of the head and neck. Wain's criteria (peripheral palisading, association with SCC, high nuclear-cytoplasmic ratio, high mitotic rate, solid growth), anti-34BE12 and CK 5/6 staining, and absence of neuroendocrine markers are mandatory for the diagnosis of BSCC. Its increasing incidence parallels that of human papilloma virus (HPV)-positive tumours for the oropharyngeal subsite. On the other hand, BSCC is frequently considered a high-grade carcinoma of poorer prognosis than its SCC counterparts, mostly due to a higher rate of distant metastases. However, BSCC has similar or better locoregional control rates and a relatively better radiosensitivity than SCC. BSCC seems to have a dual behaviour depending, at least partly, on its recently described association with HPV. The basaloid subtype of SCC, owing to its particular behaviour, should be systematically investigated along with HPV and smoking status, as those factors may be determinant in the response to treatment.

[Vertebroplasty and kyphoplasty under dual guidance (CT and fluoroscopy): radiation dose to radiologist. A comparative study]

OBJECTIVES

The goals of this study is to evaluate and compare the irradiation received by the practitioner when performing percutaneous vertebroplasty or kyphoplasty guided by CT and fluoroscopy, for precise anatomical sites.

METHODS

For each intervention, radiothermoluminescent dosimeters were carefully positioned on both orbitals, both hands, and both ankles of the practitioner.

RESULTS

Twenty-four vertebroplasties were performed in 18 patients and nine kyphoplasties on seven patients. The anatomical site that is most exposed to radiation is the right hand. The two other sites subjected to irradiation are the left hand and the left orbital. This study demonstrates a significant correlation between the irradiation dose and fluoroscopy duration, reflecting both the quantity of primary-beam radiation and backscattered radiation.

CONCLUSION

The radiation dose to radiologist is more important for kyphoplasty procedures than vertebroplasty.

A remnant tooth in an edentulous patient

OBJECTIVES

We describe a case of an unusual remnant tooth located in the paranasal sinus in a head and neck cancer patient.

CASE REPORT

A 72-year patient with a history of T3N2aM0 oropharyngeal cancer treated with chemoradiation came for systematic post-therapeutic multidetector-CT reformation (MDCT) examination. MDCT scan multi planar reformation revealed a well-limited high-density mass in his maxillary sinus, which proved to be a remnant molar tooth. Physical examination and CT imaging were performed at 26 months. Local malignancy, fungal ball and persistent oroantral fistula were ruled out.

CONCLUSION

The physio-pathogenesis of oroantral fistula (OAF) and causes of intra sinusal tooth as well as therapy are discussed in this article.

[Neck dissection following chemoradiation for node positive head and neck carcinomas]

The optimal timing and extent of neck dissection in the context of chemoradiation for head and neck cancer remains controversial. For some institutions, it is uncertain whether neck dissection should still be performed upfront especially for cystic nodes. For others, neck dissection can be performed after chemoradiation and can be omitted for N1 disease as long as a complete response to chemoradiation is obtained. The question is debated for N2 and N3 disease even after a complete response as the correlation between radiological and clinical assessment and pathology may not be reliable. Response rates are greater than or equal to 60% and isolated neck failures are less than or equal to 10% with current chemoradiation protocols. Some therefore consider that systematic upfront or planned neck dissection would lead to greater than or equal to 50% unnecessary neck dissections for N2-N3 disease. Positron-emission tomography (PET) scanning to assess treatment response and have shown a very high negative predictive value of greater than or equal to 95% when using a standard uptake value of 3 for patients with a negative PET at four months after the completion of therapy. These data may support the practice of observing PET-negative necks. More evidence-based data are awaited to assess the need for neck dissection on PET. Selective neck dissection based on radiological assessment and peroperative findings and not exclusively on initial nodal stage may help to limit morbidity and to improve the quality of life without increasing the risk of neck failure. Adjuvant regional radiation boosts might be discussed on an individual basis for aggressive residual nodal disease with extracapsular spread and uncertain margins but evidence is missing. Medical treatments aiming at reducing the metastatic risk especially for N3 disease are to be evaluated.

[Papillary thyroid microcarcinomas: review of 230 cases]

OBJECTIVES

Papillary microcarcinoma (PMC) is one of the most frequent pathological forms of thyroid cancer Here, we describe the circumstances of diagnosis and the clinical and pathological characteristics of this tumour We also analyze the therapeutic management and compare it with the recent published guidelines.

METHODS

Between 2000 and 2006, a total of 230 patients with a PMC of the thyroid gland were included in this retrospective study. We have investigated the correlations between some pathological parameters (plurifocality, lymph node invasion...) and several factors (age, gender, tumour size...).

RESULTS

The diagnosis of PMC was suspected in the preoperative period in 15% of the patients, and was confirmed intraoperatively by the pathologist in 42% of the cases. Plurifocal or bilateral PMC were discovered in respectively 30 and 17% of the patients. The rate of lymph node invasion in the central neck (level VI) was 26%. An elevated tumor size was correlated with a higher rate of plurifocal or bilateral PMC and of lymph node metastasis (p < 0.05). The indications for postoperative radioiodine therapy were reduced by approxiately 50% in the second part of our study. There were no case of thyroid PMC-related death.

CONCLUSIONS

Even for these small tumours, tumour size remains correlated with the tumour aggressiveness. The place of radioiodine therapy in the management of thyroid PMC was progressively reduced because of the good prognosis of this tumour.

Prognostic factors in 1,038 women with metastatic breast cancer

BACKGROUND

Treatment of metastatic breast cancer (MBC) remains palliative. Patients with MBC represent a heterogeneous group whose prognosis and outcome may be dependent on host factors. The purpose of the present study was dual: first, to draw up a list of factors easily available in everyday clinical practice requiring no sophisticated or costly methods and second, to provide results from a large cohort of women who underwent diagnostic and treatment at a single institution.

PATIENTS AND METHODS

From 1975 to 2005, a total of 1,038 women with MBC during their follow-up were included in this retrospective analysis. Patients were subsequently assigned to five groups according to the period of metastatic diagnosis.

RESULTS

It is shown that age at initial diagnosis, hormonal receptor status and site of metastasis are the most relevant prognostic factors for predicting survival from the time of metastastic occurrence. It is also shown that a metastasis-free interval is an easily and immediately available multifactorial prognostic index reflecting the multiparametric variability of the disease.

CONCLUSION

These fundamental observations may assist physicians in evaluating the survival potential of patients and in directing them toward the appropriate therapeutic decision.

A comparison between distal and proximal port device insertion in head and neck cancer

AIM

To compare technical feasibility and complications of radiologically arm port device implantation using arm venography exclusively (API-Group B) with chest port placement using cephalic vein cutdown (CVC-Group A), in advanced consecutive head and neck cancer patients (HNP).

METHODS

Port device placement was attempted in 225 consecutive HNP. Decision for inclusion in Group A or B was made first by the availability of the surgeon/radiologist to perform the procedure, second by contraindications of each technique. Patient transfer from one group to the other was recorded as well as technical feasibility, complications and device specific duration in this retrospective study.

RESULTS

Technical success was statistically higher in Arm Port Group (99.1%) compared to Chest Port Group (75.2%). Device specific duration rate of the whole population was 53% (95%CI) [0.47-0.60] at 6 months, 44.1% (95%CI) [24.4-37.8] at 12 months and 8% (95%CI) [4.4-14.5] at 24 months. Median follow-up was 5.55 months (range: 0.032-9.6] in Group A versus 5.90 months [range: 0.06-27.6] (p=ns) in Group B. Complication rate was 15.9% in Group A versus 8.9% in Group B corresponding to a complication rate per patient-implantation-days of 0.66/1000 patient-days (A) versus 0.42/1000 patient-days (B). Premature port device explantation rate was 4.4% (A) versus 5.4% (B). Axillary and subclavian venous thrombosis was the main complication and occurred in 12 Group A patients and three Group B patients. Venous thrombosis rate was 0.37/1000 patient-days (A) and 0.13/1000 patient-days (B) (p=0.03).

CONCLUSIONS

A few data exist about device insertion in HNP in whom venous cervical access is contraindicated. This comparative study demonstrates that both implantation techniques are safe and effective. The higher technical success rate with 0% heavy sedation, the lower venous thrombosis rate in the API group, and the 5.3% (A-B) patient transfer rate argue in favour of arm port placement in HNP. Indications for API include patients with an ipsilateral major pectoralis-myocutaneous flap, with radiodermatitis, tumour recurrence in the neck and upper chest, or with respiratory impairment.

Ultrasound-guided percutaneous radiofrequency ablation in elderly breast cancer patients: preliminary institutional experience

Breast cancer is a major source of morbidity and mortality in the elderly population and the number of patients will increase by 30% in future decades. Surgery and endocrine therapy could be considered as the standard treatment in elderly breast cancer patients, but anaesthesia for surgery requires a specific approach taking into account physiological and psychological alterations secondary to ageing. In cases with major alterations of performance status, percutaneous radiofrequency ablation (RFA) could be substituted for the surgical treatment. The aim of the current study is to evaluate the efficacy and feasibility of this technique. Five tumours in four consecutive patients (aged 79-82 years) contraindicated for surgery with symptomatic cT1-2N0M0, positive oestrogen receptor status, low grade were treated by percutaneous radiofrequency-lump ablation under local analgesia, using percutaneous ultrasound guidance. Thermal lesions were produced with RF power 30 W, at a frequency of 500 kHz. Ultrasound-guided percutaneous biopsy of the RF treated breast was performed during the follow-up. We report a successful RFA lump ablation experience in the treatment of four tumours (4/5). One local recurrence occurred within 4 months after RFA. The other biopsies taken during the follow up showed all fat necrosis within the oil cyst and no malignant cells. One abscess occurred at 9 months within the treated area. After a mean follow up of 29.4 months, all the patients are still alive without any other signs of recurrence or metastases. Ultrasound-guided percutaneous RFA is safe and feasible in the management of breast cancer in elderly patients. Nevertheless, further large comparative studies are needed in order to validate such a minimally invasive procedure in current practice.

Home infusions of biphosphonate in cancer patients: a prospective study

The objective of the study was to determine outcome and satisfaction of cancer patients treated by home-infusions of biphosphonates. 107 patients entered the study and 97 of them chose to receive infusions of zoledronic acid (Z) in the home setting. Patient satisfaction and quality of care (QoC) were assessed by a 22-item questionnaire. Changes from baseline were determined for bone pain using a 0-10 cm visual analogue scale pain score (VAS). Patients expressed a high level of satisfaction specifically with regard to nursing care. Seventy patients experienced a significant decrease in the median pain score during the home-therapy phase not due to an increased use of analgesic therapy (P = 0.03). Z was well tolerated with no major adverse events. The authors conclude that home infusions of biphosphonates, on the condition that the supportive care team is well-organized, is a safe procedure that could be advantageous for patients by increasing satisfaction and compliance with treatment.

Comparison of the epidermal growth factor receptor gene and protein in primary non-small-cell-lung cancer and metastatic sites: implications for treatment with EGFR-inhibitors

BACKGROUND

Very recent studies have suggested that EGFR gene copy number and expression obtained by fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC) should be used to predict which lung cancer patients are expected to respond to anti-EGFR treatments. However, it is still not known whether EGFR expression differs in metastases compared to primary non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

EGFR status was analysed by IHC and FISH on tumor samples of primary NSCLC and at least one distant metastatic lesion in 30 patients.

RESULTS

Ten cases (33.3%) showed primary tumor/metastasis discordance by IHC analysis (n = 30): in seven cases, EGFR was expressed in the primary tumor but not in the metastasis, while three samples showed EGFR expression in the metastasis but not in the primary tumor (Pearson correlation coefficient = 0.331, P = 0.0074). By FISH (n = 26), seven (27%) cases were discordant: six cases showed a high-level of EGFR polysomy in the primary tumor but not in the metastasis and one case showed a high-level of EGFR polysomy in the metastasis but not in the primary sample (Pearson correlation coefficient = 0.52, P = 0.007).

CONCLUSION

EGFR expression is not stable during metastatic progression in a significant proportion of NSCLC. These findings have to be considered in future prospective studies.

[Target volumes in radiotherapy - head and neck tumors intensity - modulated radiation therapy (IMRT) of nasopharyngeal carcinoma: practical aspects in the delineation of target volumes and organs at risk]

The objective of this paper is to give some practical landmarks for the delineation of target volumes and organs at risk in Intensity Modulated Radiation Therapy for Nasopharyngeal Carcinoma. This delineation, drawn from anatomo-clinical data, natural history of the disease and radiological pre-treatment evaluation, seems to be easier to define than the delineation of other head and neck cancer localisations (oropharynx and oral cavity for example). Experience inside national and international cooperative groups should tend to standardize this initial and fundamental step of Nasopharyngeal Conformal Radiotherapy.

Radiological and surgical placement of port devices: a 4-year institutional analysis of procedure performance, quality of life and cost in breast cancer patients

PURPOSE

The present study is designed to evaluate and compare percutaneous radiologic arm port (R) and surgical subclavian port (S) devices in two homogeneous sets of breast cancer patients in terms of safety, efficacy, quality of life (QoL) and cost analysis.

MATERIAL AND METHODS

This study involved a retrospective review of a prospective databank including 200 consecutive port device implantation attempted procedures performed over a 4-year period, in two similar groups of 100 breast cancer women who underwent either the surgical cephalic vein cutdown approach or the percutaneous basilic vein catheterization for intravenous adjuvant chemotherapy. Parameters analyzed included technical success, procedure duration, complications, QoL and cost evaluation for both techniques.

RESULTS

The success rate for port implantation was higher for R than for S placement (96% versus 91%). Mean implant duration time was 5.6 and 7.6 months for R and S, respectively. The overall complication rate was 10 and 16% for R and S, respectively. Mean implant duration time, without any complication or death, was 6.4 and 7.8 months for R and S, respectively. Six and seven percent for R and S, respectively, had to be removed prematurely. Both techniques exhibited very good QoL. Direct costs were respectively euro 230.8 and 219.1 for R and S, respectively.

CONCLUSION

The significant advantages of R over S include higher success rate, higher cosmetic results despite a 15% relative overcost for R placement. Both are indicated for breast cancer chemotherapy treatment, nevertheless R placement is mandatory in anxious patients who fear surgery, in case of previous cervico-thoracic irradiation or upper extremity venous thrombosis, or in patients at risk of respiratory insufficiency.

Percutaneous treatment in patients presenting with malignant cardiac tamponade

The percutaneous treatment of pericardial effusion resulting in cardiac tamponade has undergone an evolution in recent years with the use of less invasive drainage techniques in selected cases. To determine optimal therapy modalities for oncology patients with malignant pericardial tamponade (MPT), the authors review their institutional experience with percutaneous needle puncture routes, means of imaging-guided drainage and percutaneous management of the pericardial fluid effusion (pericardial sclerosis and balloon pericardiotomy). Advantages and limits of the percutaneous techniques will be compared to the surgical treatment.

Imaging of percutaneous pericardioperitoneal shunt in patient with malignant cardiac tamponade

Patients with malignant pericardial tamponade have a poorer prognosis than patients with non malignant effusion in a neoplastic context. Pericardial metastases occur frequently in advanced-stage disease patients, in 5-10% of all patients with cancer. Among a personal series of five patients who underwent the same procedure, we report characteristic imaging features of a 16-year-old man presenting with malignant tamponade, who was successfully treated by percutaneous pericardioperitoneal shunt. Percutaneous balloon pericardiotomy is a well-tolerated, safe, and well-known technique, but little has been described concerning imaging the percutaneous pericardioperitoneal shunt. This life-saving procedure should be used for recurrence of malignant tamponade and should also be considered for initial treatment. Advantages of the percutaneous procedure include minimal discomfort, low morbidity rate, and efficiency similar to surgical pericardiotomy without sedation.

Liver Metastases from Head and Neck Squamous Cell Carcinomas: Radiological and Biological Features

BACKGROUND

Liver metastases from head and neck cancer are rare (4.4%) and associated with a poor prognosis (median survival 4 months). The objective of the present study was to evaluate the radiological and biological features of liver metastases from head and neck (H and N) squamous cell carcinomas in 24 patients among 550 recurrent H and N cancer patients in our data bank.

RESULTS

At first presentation of liver nodules, liver enzyme levels (LEL) were found to be abnormal in 46% of patients (n = 11). Ultrasound features included miscellaneous presentations such as hypoechogenic (n = 21), hyperechogenic hemangioma-like lesions (n = 2), owl's eye (n = 2) or cyst-like liver nodules (n = 3). Hepatomegaly was present in 48% of the cases without any sign of portal hypertension and without any ascites. 1 month before death, all patients presented with abnormal LEL. Liver imaging showed an increase of 1.8x in size and of 2x in number of the tumor nodules. Hepatomegaly was present in 54%. Little ascites appeared in 2 cases, with no evidence of portal hypertension or liver insufficiency. Median disease-free interval and overall survival from recurrence were 10.8 and 4 months, respectively.

CONCLUSION

Ultrasound is convenient, cheap, without any side effect, and can provide additional information about liver metastases in H and N cancer patients. In patients with a history of H and N carcinoma ultrasound should be used to screen for isolated hepatic nodules even in the presence of normal liver function and if LDH elevation should be the only biological sign of alert.

Traitement des images et radiothérapie

Medical images are of great importance in radiotherapy, which became a privileged application field for image processing techniques. Moreover, because of the progression of the computers' performances, these techniques are also in full expansion. Today, the recent developments of the radiotherapy (3DCR, IMRT) offer a huge place to them. Effectively, they can potentially answer to the precision requirements of the modern radiotherapy, and may then contribute to improve the delivered treatments. The purpose of this article is to present the different image processing techniques that are currently used in radiotherapy (including image matching and segmentation) as they are described in the literature.

Late presentation of a gastrocolic fistula after percutaneous fluoroscopic gastrostomy

Gastrocolic fistula (GCF) has previously been described with percutaneous endoscopic gastrostomy procedures. However the present case of GCF is to our knowledge the first reported in the literature. It developed as a complication of the fluoroscopic technique three months after percutaneous fluoroscopicically guided gastrostomy-tube insertion. GCF was symptomless and was discovered during button replacement in a 74-year-old head and neck cancer patient. In patients with complex upper abdominal anatomy, the use of US or CT should be recommended to avoid such problem.

[2003 update of Standards, Options and Recommandations for radiotherapy for patients with salivary gland malignant tumors (excluding lymphona, sarcoma and melanoma)]

CONTEXT

The "Standards, Options and Recommendations" (SOR) project, which started in 1993, is a collaboration between the Federation of French Cancer Centers (FNCLCC), the 20 French Regional Cancer Centers. 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 the outcome of cancer patients.

OBJECTIVES

To update clinical practice guidelines for the management of patients with salivary gland malignant tumors previously validated in 1997. These recommendations cover diagnosis, treatment and follow-up of patients with these tumors.

METHODS

The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts who define the CPGs according to the definitions of the Standards, Options and Recommendations project. Once the guidelines have been defined, the document is submitted for review by independent reviewers.

RESULTS

This article presents the updated clinical practice guidelines concerning irradiation of patient with salivary gland tumors. The main recommendations are: 3 dimensional conformal radiotherapy (with or without intensity modulation) or 2D irradiation can be used; for surgical complete resected patients, postoperative photon radiotherapy should not be used in case of low grade stage I and 11 tumors(standard, level of evidence B2) but should be used for high grade stage II, II and IV tumors and for low grade stage III and IV tumors(standard, level of evidence B2). Neutron therapy should not be used in all of these cases (standard, level of evidence D); for patients presenting an incomplete macroscopic or microscopic surgical residual disease, postoperative irradiation must be delivered(standard). Neutron or photon therapy can be either delivered (options); for non operable patients neutron or photon therapy can be either delivered (options, level of evidence B2); for unresectable tumors or in case of recurrent neoplasms, exclusive neutron therapy or surgical tumor reduction combined with postoperative photon beam irradiation can be proposed (options, level of evidence C).

[Medical complications and medical legal pitfalls concerning interventional radiological procedures on the breast]

Radiological interventional procedures on the breast are still work in progress. Initiation of percutaneous macrobiopsy techniques such as stereotactic or ultrasound-guided core biopsy, mammotomy or Abbi Site-Select procedures allows the physician to expect a high accuracy for the diagnosis of non palpable suspected breast abnormalities, thus eliminating the need for at least half of the surgical biopsies done for this indication. Furthermore, the absence of any lasting post-procedural changes on follow-up mammography contrasts with the scarring associated with traditional surgical open biopsy and obviates confusion in subsequent mammographic interpretation. Recently, development of percutaneous radiofrequency or cryotherapy ablation of breast cancer has been related. All these cost-saving procedures lead to medical and potential medical legal pitfalls that will be discussed.

Coeliac plexus block: utility of the anterior approach and the real time colour ultrasound guidance in cancer patient

AIMS

The aim of our study was to demonstrate the efficacy of ultrasound-guidance compared with computed tomography (CT) guidance for coeliac plexus block in cancer patients.

METHODS

Coeliac plexus block (30 ml ethanol) was performed in 34 cancer patients (sex ratio: 10F, 24M), mean age: 54.8 years (range 26-67) under CT (n=21) and ultrasound-guidance (n=13). All patients had excruciating epigastric and generalized abdominal pain caused by cancer of the pancreas (n=13) or upper abdominal viscera (n=9) or a malignancy of extra-digestive origin (n=12). Feasibility and complication rates were analysed.

RESULTS

Notable pain relief was obtained in 27 (79%) of the patients. The technical success rate was 100% for CT-guidance and 93% (13/14) for ultrasound guidance. There were six minor complications (17%): chemical peritonitis (n=2), orthostatic arterial hypotension (n=2) and transient left shoulder pain (n=2), no major complications occurred. The target route was transhepatic in 6/13 of the ultrasound cases and mean length was 6 cm (range 3-12 cm). Colour Doppler sonography improved visualization of the 21 Gauge Chiba needle when the needle shaft was vibrated. Echogenic foci were observed around the origin of the coeliac trunk and superior mesenteric artery in all cases. CT coeliac block was successfully performed after failure of ultrasound guidance in one patient.

CONCLUSION

Ultrasound guidance is safe and effective and should be attempted for coeliac plexus block whenever possible.

Chemotherapy- and radiotherapy-induced mucositis in head and neck cancer patients: new trends in pathophysiology, prevention and treatment

Mucositis is the intensity-limiting toxicity in the management of locally advanced non-resectable head and neck cancer with radiotherapy and chemotherapy. New radiation modalities (hyperfractionation and/or acceleration) as well as combined modality regimens in this situation induce higher rates of acute toxicity. Hyperfractionation, for example, allows higher control rates, with few late toxicities, but it slightly increases acute mucositis. The addition of chemotherapy introduces systemic toxicity and can exacerbate local tissue reactions when used concurrently with radiotherapy. Mucositis is recognized as the principal limiting factor to further treatment intensification. As local regional control and overall survival are related to dose-intensity in this case, further research into the assessment, analysis, prevention and treatment of mucosal toxicity is not only crucial to improvement in quality of life, but certainly also to improved rates of disease control. Several topical and systemic treatments are directed to the decrease and the acceptance of this acute toxicity, but few have shown a significant preventive effect. The efficacy of low-level laser therapy in the management of such toxicity could hence yield important developments with this method in the field of oncology.

[132 grams of tamoxifen: ultrasonographic and MRI appearance of endometrial carcinoma]

Endometrial carcinoma is a rare iatrogenic complication due to the adverse estrogenic like effect of Tamoxifen on the uterine mucosa. We report the delayed case of an endometrial carcinoma after an unusual twleve year long daily administration of Tamoxifen (cumulative dose = 131 g). Endovaginal contrast ultrasound examination (Levovist, Schering, Germany) and MRI appearances are described.

Concomitant twice-a-day radiotherapy and chemotherapy in unresectable head and neck cancer patients: A long-term quality of life analysis

BACKGROUND

The purpose of this study is to make a comparative analysis between acute toxicity with late toxicity. This study is based upon a French quality of life (QoL) questionnaire in a cohort of advanced head and neck (H&N) cancer patients treated by concomitant twice-a-day continuous radiotherapy with no acceleration and chemotherapy with cisplatin and 5-fluorouracil.

METHODS

From September 1992 to November 1997, a prospective data bank of 91 patients was constituted. In November 1999, 31 patients were still alive and followed for more than 3 years. All patients had stage IV strictly unresectable squamous cell carcinoma of oropharynx or hypopharynx. A French specific H&N cancer QoL questionnaire was used at the end of radiotherapy and at the last date of follow-up of each patient (during 1999). p values reflect comparison of percentages obtained at the end of treatment with percentages at long-term follow-up. Statistical analysis was performed using chi(2) test (p <.05 considered as significant). Percentages obtained by the QoL questionnaire correspond to moderate-severe problems only.

RESULTS

Twenty-nine of 31 (94%) patients participated in the QoL study. Acute treatment toxicities were severe with declines in virtually all QoL and functional domains. Globally, with an average long-term follow-up of 4.5 years (range 3-7 years after treatment), there is a statistical improvement in the following symptoms: dry mouth and sticky saliva (97% versus 55%, p <.05); tasting problems (35% versus 21%, not significant); swallowing problems (77% versus 36%, p <.05); and H&N pain (86% versus 9%, p <.05). Financial problems were not improved (21% versus 14%, not significant), and psychological problems (59% versus 5%) were statistically significant. Fourteen of 29 (48%) patients were drinking and 8 of 29 (28%) were smoking at long-term follow-up; at the diagnosis they were 86% and 90%, respectively. At long-term follow-up 22 of 29 presented good or very good QoL, and 25 of 29 said they had improved their initial QoL.

CONCLUSION

The interest of twice-a-day radiotherapy with concomitant chemotherapy is to increase total radiotherapy equivalent dose without increasing late toxicity and also to improve locoregional control, survival, and long-term QoL/effectiveness ratio. Best supportive care is recommended to obtain both good QoL and cancer control in a long-term follow-up.

[Concomitant bifractionated radiotherapy and chemotherapy with cisplatin and 5-fluorouracil in locally progressive, non-resectable epidermoid carcinomas of the pharynx: ten years experience at the Antoine Lacassagne center]

PURPOSE

Patients suffering from locally advanced unresectable squamous cell carcinoma of the oropharynx and hypopharynx treated with radiotherapy alone have a poor prognosis. More than 70% of patients die within 5 years mainly due to local recurrences. The aim of this study was to evaluate retrospectively the Antoine Lacassagne Cancer Center's experience in a treatment by concomitant bid radiotherapy and chemotherapy. Evaluation was based on analysis of the toxicity, the response rates, the survival, and the clinical prognostic factors.

PATIENTS AND METHODS

From 1992 to 2000, 92 consecutive patients were treated in our single institution. All of them had stage IV, unresectable squamous cell carcinoma of the pharynx and they received continuous bid radiotherapy (two daily fractions of 1.2 Gy, 5 days a week, with a 6-h minimal interval between fractions). Total radiotherapy dose was 80.4 Gy on the oropharynx and 75.6 Gy on the hypopharynx. Two or three chemotherapy courses of cisplatin (CP)-5-fluorouracil (5FU) were given during radiotherapy at 21-day intervals (third not delivered after the end of the radiotherapy). CP dose was 100 mg/m2 (day 1) and 5-FU was given as 5-day continuous infusion (750 mg/m2/day at 1st course; 430 mg/m2/day at 2nd and 3rd courses). Special attention was paid to supportive care, particularly in terms of enteral nutrition and mucositis prevention by low-level laser energy.

RESULTS

Acute toxicity was marked and included WHO grade III/IV mucositis (89%, 16% of them being grade IV), WHO grade III dermatitis (72%) and grade III/IV neutropenia (61%). This toxicity was significant but manageable with optimised supportive care, and never led to interruption of treatment for more than 1 week, although there were two toxic deaths. Complete global response rate at 6 months was 74%. Overall global survival at 1 and 2 years was 72% and 50% respectively, with a median follow-up of 17 months. Prognostic factors for overall survival were the Karnofsky index (71% survival at 3 years for patients with a Karnofsky index of 90-100% versus 30% for patients with a Karnofsky index of 80% versus 0% for patients with a Karnofsky index of 60-70%, p = 0.0001) and tumor location (55% at 3 years for oropharynx versus 37% for panpharynx versus 28% for hypopharynx, p = 0.009).

CONCLUSION

These results confirm the efficacy of concomitant bid radiotherapy and chemotherapy in advanced unresectable tumor of the pharynx. The improvement in results will essentially depend on our capacity to restore in a good nutritional status the patients before beginning this heavy treatment.

Renal failure secondary to thrombotic complications of suprarenal inferior vena cava filter in cancer patients

PURPOSE

To evaluate renal function before and after suprarenal inferior vena cava (IVC) filter placement.

METHODS

We describe, in a personal series of 13 consecutive cases (all of them stage IV cancer patients, one LGM filter, one Antheor filter, 11 Greenfield filters) in our institution, two cases of fatal renal vein thrombosis after placement of a suprarenal filter. Evaluation of renal function was based on serum urea (in mmol/L; normal 3.30-6.60), serum creatinine (in micromol/L; normal <115.1), and calculation of serum creatinine clearance.

RESULTS AND CONCLUSION

This study suggests that in advanced-stage cancer patients who have a single functional kidney, renal functional insufficiency, or previous renal vein thrombosis, IVC filter placement above the renal veins may not be appropriate. Suprarenal filter placement should be performed only after analysis of predicted survival, after detailed discussions with the patient, and most importantly after renal function evaluation.

Strecker stent migration to the pulmonary artery: long-term result of a "wait-and-see attitude"

Accidental dislodgement of an endoprosthesis into the right cavities or the pulmonary artery is a rarely described complication of percutaneous venous stenting. In such cases the migrated stent needs to be promptly extracted by percutaneous techniques in order to avoid any major complication. We report the first case of a delayed Strecker stent migration from the left innominate vein into the right pulmonary artery, successfully managed with anticoagulant therapy and a "wait-and-see" attitude. The advanced stage-disease (metastatic cancer patient) and the large-caliber stent in a disease-free pulmonary artery led us to adopt this unorthodox attitude, as compared with the current clinical practice.

Superior vena cava obstruction: is stenting necessary?

No therapy is currently available for patients with recurrent vascular obstruction of the superior vena cava (SVC) caused by tumor regrowth after chemotherapy or radiation therapy. Intravascular stenting is a new option for the treatment of vena cava syndrome. Forty cancer patients with SVC syndrome (SVCS) were evaluated by computed tomography (CT) and venography. The SVC or its tributaries were stenosed or thrombosed in all patients. The etiology was malignant in all but 2 cases: non-small-cell lung carcinoma (n = 28), mediastinal nodal metastasis (n = 5), lymphoma (n = 2), pleural mesothelioma (n = 2), small-cell lung carcinoma (n = 1), and postradiation fibrous mediastinitis (n = 2). Stenting was achieved in 39 of the 40 patients, and clinical symptoms subsided in 92%. Stents remained patent in 36 of these 39 patients throughout a mean follow-up of 24 weeks (range 3 days to 24 months). SVC stenting is safe, effective and allows rapid cure of SVCS and port catheter implantation in patients in poor health.