[Dental management of head and neck irradiated patients]. / Prise en charge dentaire des patients irradiés en région cervico-faciale.

The oncological management of head and neck tumours is well known and standardized. Radiotherapy is one of the effective tools. However, it induces major changes in healthy tissues: teeth, gums, mucous membranes, salivary glands and bones. Some, like mucositis, are immediate and often reversible; others, like hyposialia or fibrosis, are late effects and often irremediable. These changes greatly affect oral health and make its management more complex. Dental management also becomes a capital element of the care path but, unfortunately, often remains neglected by the patient but also by some practitioners. It concerns all the stages of the clinical course: initial assessment, cancer treatment itself and long-term follow-up. If neglected, the patient's quality of life will be affected and complications, sometimes serious, such as osteoradionecrosis, may occur. Specific care recommendations for maintaining oral health are mentioned, especially for those patients requiring oral cavity irradiation.

La prise en charge carcinologique des tumeurs cervico-faciales est bien connue et codifiée. La radiothérapie fait partie des outils efficaces proposés. Elle entraîne cependant de profondes modifications tissulaires : dents, gencives, muqueuses, glandes salivaires, os. Certaines, comme la mucite, sont immédiates, et souvent réversibles; d'autres, comme l'hyposialie ou la fibrose, s'installent tardivement et souvent définitivement. Ces remaniements altèrent fortement la santé bucco-dentaire et rendent la prise en charge plus complexe. L'approche dentaire devient ainsi un élément capital du trajet de soins. Elle reste, malheureusement, souvent délaissée par le patient lui-même, mais aussi parfois par le praticien. Cette prise en charge concerne toutes les étapes du parcours : bilan initial, traitement carcinologique en soi et suivi à long terme. Si négligée, la qualité de vie du patient sera affectée et des complications, parfois graves, telle l'ostéoradionécrose, peuvent survenir. Sont évoquées ici des recommandations spécifiques de prise en charge bucco-dentaire dans le décours d'une irradiation portant sur la cavité buccale.

[Role of radiotherapy in the treatment of plantar fasciitis]. / Place de la radiothérapie dans le traitement de la fasciite plantaire.

Plantar fasciitis is the most common cause of talalgia in adult. It can affect a variety of individuals and its etiology is still unknown. Several factors are probably involved (repeated micro-traumatisms excessive tension, chronic inflammation…). In plantar fasciitis bone exostosis can be observed. The latter may also result into a functional incapacity due to major pain and therefore has a major impact on the quality of life. Several treatments with different efficacy are proposed to the patient. The role of radiotherapy is very limited, even if it's more frequently applied in Germany. The main goals of this article are to evaluate the place of the radiotherapy in the therapeutic approach, to confirm its efficacy and to assess the associated risks.

La fasciite plantaire est la cause la plus fréquente de talalgie chez l'adulte. Elle affecte une population hétérogène et son étiologie reste inconnue, même s'il existe probablement une origine multi-factorielle (contraintes répétées, tension excessive, inflammation chronique…). La talalgie peut être associée à une exostose osseuse ou éperon calcanéen inférieur. Elle peut être source d'incapacité fonctionnelle en raison de douleurs importantes associées qui peuvent entraîner une altération majeure de la qualité de vie. De multiples traitements peuvent être proposés aux patients. La radiothérapie a une place très restreinte dans l'arsenal thérapeutique, même si elle est plus fréquemment utilisée chez nos voisins germaniques. Notre article a pour but de discuter de la place de la radiothérapie dans le schéma thérapeutique, d'en confirmer l'efficacité et d'en évaluer les risques associés.

[Melanoma : the patient's care pathway. From diagnosis to therapy]. / Le mélanome : le trajet de soins du patient. Le mélanome : le trajet de soins du patient Du diagnostic au traitement Du diagnostic au traitement.

The management of melanoma is a typical example of a pluridisciplinary approach, in order to provide the patient with a rapid and adequate treatment plan after the initial diagnosis. Both in the domains of dermatology, pathology and oncology, enormous progress has been made. Recent advances permit a rapid access to diagnostic techniques using teledermoscopy, an improved diagnostic accuracy using dermoscopy, pre-interventional high-frequency ultrasound and optical coherence tomography, a determination of risk factors using immunohistochemistry and genetic analyses on the pathology samples. Furthermore, the development of immunotherapies, in particular the anti-PD1 antibodies, and the directed therapies, therapies permitting an increased number of patients to experience an increased survival with an acceptable tolerance profile in the event of metastatic lesions. This article describes the patient's care pathway, from the initial diagnosis, staging, to an eventual treatment and follow-up.

Le traitement du mélanome est un exemple type de collaboration multidisciplinaire, afin de pouvoir garantir au patient une prise en charge rapide dès le moment de la détection de la lésion. Tant au niveau dermatologique, anatomopathologique et oncologique, d'énormes progrès ont eu lieu ces dernières années. Ils permettent un accès au diagnostic de plus en rapide par la télédermoscopie, une précision diagnostique accrue par la dermoscopie, l'ultrason à haute fréquence et la tomographie par cohérence optique, une détermination des facteurs de risque immunohistochimiques et génétiques sur les analyses anatomo-pathologiques ainsi que le recours à des immunothérapies, notamment les anti-PD1, et à des traitements ciblés. Ces nouveaux traitements permettent souvent une plus longue survie du patient, avec un profil de tolérance acceptable en cas de lésions métastatiques. Cet article reprend le trajet de soins du patient, du diagnostic initial et du staging au traitement éventuel avec son suivi.

[Locally advanced and metastatic cutaneous squamous cell carcinoma treated with cemiplimab]. / Carcinome spinocellulaire cutané localement avancé et métastatique traité par cémiplimab.

The treatment of locally advanced or metastatic cutaneous squamous cell carcinoma (cSCC) essentially relies on surgery and eventually radiotherapy of the treated site and afferent lymph nodes. Unfortunately, some cases are no candidates for surgery or radiotherapy and a systemic treatment may be indicated. Chemotherapies are only partially efficacious and associated with potential toxicities. A recent study evaluating the efficacy and tolerance of cemiplimab, a PD1 antagonist for locally advanced and metastatic cSCC demonstrated an objective response rate of 49 % and 47 % for locally advanced and metastatic cSCC, while maintaining a response of at least 6 months of 63 % and 60 %, respectively. We present a clinical case of a patient with a locally advanced cSCC of the forehead with bone resorption and cervical lymphadenopathies. After failure of multiple surgical interventions and radiotherapies, he responded partially to cemiplimab immunotherapy with a good safety profile.

Le traitement du carcinome spinocellulaire cutané (cSCC) localement avancé et/ou métastatique repose essentiellement sur la chirurgie et, éventuellement, sur une radiothérapie de la zone chirurgicale et de l'aire ganglionnaire afférente. Malheureusement, certains cas ne sont plus opérables ou accessibles à la radiothérapie et un traitement systémique est alors indiqué. Les chimiothérapies sont peu efficaces et potentiellement toxiques. Une étude récente évaluant l'efficacité et la tolérance du cémiplimab, un antagoniste PD1, dans les cSCC localement avancés et métastatiques, démontre une réponse objective confirmée de 49 % et de 47 %, respectivement, avec un maintien de la réponse d'au moins 6 mois de 63 % et de 60 %, respectivement. Nous présentons le cas d'un patient avec un cSCC localement avancé au niveau du front, avec effraction osseuse et adénopathies cervicales, ayant eu de multiples chirurgies et radiothérapies. Il a présenté une réponse partielle au cémiplimab avec un profil de tolérance satisfaisant.

[Could we consider that radiotherapy is effective outside the irradiation area ? The abscopal effect]. / Peut-on considérer que la radiothérapie agit en dehors du site irradié ? L'effet abscopal.

Radiotherapy is known for its action on local tumoral control. However, it is also able to induce immunomodulatory effects at a systemic level. The abscopal effect (from latin ab scopus which means «away from the target¼) is an illustration of this phenomenon. It is defined as a tumor regression observed outside and at a distance of the irradiation fields. The potential application of this effect of treatment in disseminated cancers is a fast-growing field of research. The optimal therapeutic strategy to achieve this effect remains unknown.

La radiothérapie, connue pour son action sur le contrôle tumoral local, est également capable d'induire des effets immuno-modulateurs systémiques. L'effet abscopal (du latin ab scopus qui signifie «à distance de la cible¼) décrit la régression tumorale observée à distance de la zone d'irradiation. L'exploitation thérapeutique de celui-ci comme traitement des cancers disséminés est un domaine de recherche en plein essor. Actuellement, les modalités thérapeutiques optimales visant à obtenir cet effet demeurent inconnues.

[What is the standard treatment approach for a cervical lymph node metastasis from a squamous cell carcinoma of unknown origin?]. / Exploration et traitement d'un carcinome épidermoïde ganglionnaire cervical sans primitif décelé.

The diagnostic work-up of cervical lymph node metastases from an occult primary tumour in the head and neck region is well established. PET-scan, which was controversial, is nowadays an integral part of it. Common therapeutic strategies include neck dissection followed by extensive irradiation of pharyngeal mucosa and bilateral lymph node areas. Chemotherapy is often added to these treatment modalities, especially if negative prognostic factors are present on the pathological specimen. However, its therapeutic benefit is not yet proven. There are numerous phase II studies available in the literature, sometimes with controversial conclusions. Therefore, as long as there are no data issued from randomized controlled trials, the treatment decisions are copied from the ones which are used when the primary tumour is well identified in the head and neck area.

[Multidisciplinary treatment of glioblastoma]. / Le traitement multidisciplinaire du glioblastome.

Glioblastoma is a primary brain tumor that occurs most often in elderly patients. Despite improved management, the prognosis of this cancer remains poor. This review describes the multidisciplinary management of the patient with glioblastoma. It includes surgery, radiation therapy and chemotherapy.

[Radiotherapy and urogenital Paget disease]. / Le cas clinique du mois: Radiothérapie dans le cadre d'une maladie de Paget touchant la région génitale.

Urogenital Paget disease is usually treated by surgery. However, in case of recurrence or if multilating surgery is foreseen, radiotherapy seems to open a reasonable alternative. We report a successful treatment with radiotherapy in a patient with urogenital Paget's disease.

[Neoadjuvant chemotherapy in head and neck cancer]. / Chimiothérapie néoadjuvante dans les cancers "tête et cou".

Head and neck cancer represent 5% of all cancer and is often diagnosed at advanced stage. Treatment requires a multidisciplinary approach and relies on surgery, radiotherapy and/or chemotherapy. In locally advanced disease, chemotherapy has been shown to improve survival, particularly when delivered concomitantly with radiotherapy (6.5% absolute benefit in overall survival. Although induction or neoadjuvant chemotherapy has been much studied, no clear benefit has been identified but for larynx preservation. New chemotherapy regimens with adjonction of taxanes have drawn attention again on induction chemotherapy. Several randomised controlled trials have demonstrated improved response rate, disease free survival, or overall survival when docetaxel is added to cisplatin and 5 FU as induction chemotherapy. A definitive proof of the benefit of the induction approach is still lacking. To date, induction chemotherapy can only be recommended with the aim of preserving laryngeal function. Ongoing trials are expected to validate or rule out the induction strategy as a standard approach in locally advanced head and neck cancer.

[Monoclonal antibodies for the treatment of head and neck cancer]. / Place des anticorps monoclonaux dans le traitement des tumeurs de la tête et du cou.

Monoclonal antibodies are now part of the armamentarium available for the treatment of head and neck cancer. Cétuximab, a monoclonal antibody targeting EGFR, improves overall survival as compared with radiotherapy alone as radical treatment of locally advanced head and neck cancer. It is now reimbursed in Belgium after multidisciplinary discussion if cisplatin is contra-indicated. In the metastatic setting adding cétuximab to platinum based chemotherapy improves overall survival as compared with chemotherapy alone, a first-time event over a 30-year period, unfortunately not yet accessible to the Belgian patients. Other monoclonal antibodies targeting EGFR or VEGF are also currently under investigation while cétuximab is being explored in the induction, the maintenance or the post-operative radiotherapy settings.

[Head and neck tumors: standards of care and new approaches]. / Les tumeurs de la sphère ORL: standards de traitement et nouvelles approches en radiothérapie.

We intend to review the general value of radiotherapy in the management of head and neck cancer. Our aim is to define a treatment protocol which is evidence-based and therefore of use in daily clinical practice. There is general agreement on the efficacy of the concomitant schedules combining radiotherapy and chemotherapy, both in the adjuvant setting as well as in the exclusive non-surgical approach. This however does not preclude further research aiming at optimizing the therapeutic index. As far as neoadjuvant chemotherapy is concerned, applied prior to radical local treatment, there are no conclusive data available which allows us to implement this treatment option in routine clinical practice. This approach deserves further investigations and patients should be entered in well designed prospective randomized trials.

[Dosimetry of small-size photon beams]. / Dosimétrie des faisceaux de photons de faibles dimensions.

A high performance standard radiotherapy treatment unit could be used to perform stereotactic radiosurgery. The dosimetric aspects of stereotactic irradiation with small size photon beams (energies from 5 to 25 MV produced by electron linear accelerator or gamma-rays produced by cobalt-60 treatment unit) are analyzed. The diameter of circular beams used are 5 to 40 millimeters wide at the isocenter of the treatment unit. The dosimetry of small x-ray fields is complicated by two factors: the relationship between detector size and field size dimensions, and the lack of lateral electron equilibrium. The large dose gradients outside the beam's central axis require dosimetry techniques with higher spatial resolution. To determine the best dosimetry system for measurements at the beam's small focal point, particularly for measurement of the field size dependent on output factors, several different detectors were investigated: ionization chamber, silicon diode, diamond detector, thermoluminescent dosimeter, and film. Ionization chamber, which presents a sensitive volume smaller than 0.02 cm3, is the most commonly recommended detector for field diameter above 8 mm. Current representative examples of dosimetric measurements for different x-ray energies, including percent depth dose, tissue maximum ratios, beam profiles (off axis ratios), and output factors, are presented and discussed. As well, the dosimetric characteristics of small photon beams are detailed.

[How I treat...oropharyngeal mucositis associated with radiotherapy for head and neck cancer]. / Comment je traite ... la mucite bucco-pharyngée lors d'une radiothérapie cervico-faciale.

Oral mucositis the major acute effect of head and neck radiotherapy. According to the degree, irradiation may be compromised in dose and overall time with consequences on outcome. Up to now there is no standard accepted protocol. A strict program of local and general hygiene is mandatory. Analgesics are often required. Amifostine acts as a protector of salivary glands GM-CSF and G-CSF stimulate proliferation of mucosal basal cells. Sucralfate plays a barrier role. Camomile plant extract is anti-inflammatory, well tolerated and cheap. Povidone-iodine is better than chlorhexidine as an antiseptic agent. PTA lozenges with polymixin E, tobramycin and amphotericin B showed a marked power of selective microbial decontamination.

[Mandibular osteoradionecrosis: sword of Damocles of radiotherapy for head and neck cancers?]. / L'ostéoradionécrose mandibulaire: épée de damoclès de la radiothérapie cervico-faciale?

Radiotherapy of head and neck cancer is efficient but may have severe late effects. Although unfrequent, mandibular radionecrosis is the most dreadful. A cascade of events leads from hyposialia to bone destruction through extensive caries and trauma linked to tooth removal. Prevention is based on oral hygiene and use of daily topical fluorides. Antibiotics and hyperbaric oxygen can be effective as a conservative management. Progressive osteonecrosis is best treated by mandible resection and reconstruction with microvascular free bone flaps. Patient compliance to prophylaxis is of major importance. The need for periodic follow-up under the supervision of the radiation oncologist is stressed and illustrated by a clinical case having experienced disastrous consequences.