Osteosarcomas of the mandible: multidisciplinary management of a rare tumor of the young adult a cooperative study of the GSF-GETO, Rare Cancer Network, GETTEC/REFCOR and SFCE.

BACKGROUND: Mandibular osteosarcomas (MOS) mostly affect young adults. Their treatment is extrapolated from that of extragnathic osteosarcomas. MATERIAL AND METHODS: A retrospective multicooperative group study was conducted to determine the impact of chemotherapy, adjuvant radiation therapy and surgery on outcomes and to identify prognostic factors. This ethical committee-approved study included a centralized review of histology slides and operative reports. RESULTS: Of 111 patients, 58.6% were male, median age 35 years (13%, ≤18 years). Histology was osteoblastic, chondroblastic, fibroblastic, conventional not otherwise specified and others in 39.6%, 30.6%, 8.1%, 12.6% and 8.0%, respectively. Pathological World Health Organisation grades were low, intermediate and high grade in 6.4%, 11.8% and 81.8%, respectively. Surgery was carried out for 94.5% of patients. Neoadjuvant chemotherapy (mixed protocols) was carried out in 93.1% of patients. Postoperative chemotherapy and radiotherapy were carried out in 54.7% and 23.8%, respectively. Median follow-up was 59.6 months (range). Five-year local control, metastasis-free, disease-free and overall survival rates were 64.6%, 68.9%, 53.2% and 69.2%, respectively. Survival was significantly associated with age, tumor size and surgery. Wide surgery with clear margins and free flap reconstruction was the strongest prognostic factor. Neoadjuvant chemotherapy improved disease-free and metastatic-free survival and increased clear margins rates from 50% to 68%. Intermediate grades behaved like high grades in terms of metastatic-free and disease-free survival. CONCLUSION: This homogeneous series is the largest to date and emphasizes the major impact of clear margins and multidisciplinary management. Neoadjuvant chemotherapy improves disease-free survival and should be recommended for both high and intermediate grade MOS.

[Discoscanner: indications, technique, tips and tricks, interpretation]. / Discoscanner: indications, technique, trucs et astuces, interprétation.

Discography test associated with the scanner (discoscanner) is an exam that has been a renewed interest in recent few years. Thanks to the emergence of new interventions such as disc prosthesis, the procedures require confirmation of the disc level to deal with and the origin of discogenic symptoms. The aim of this paper is to describe the techniques, challenges and tips as well as the interpretation of functional and morphological examination.

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.

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.

Radiotherapy of sinonasal cancers.

We present the update of the recommendations of the French society of radiotherapy and oncology on the indications and the technical methods of carrying out radiotherapy of sinonasal cancers. Sinonasal cancers (nasal fossae and sinus) account for 3 to 5% of all cancers of the head and neck. They include carcinomas, mucosal melanomas, sarcomas and lymphomas. The management of sinonasal cancers is multidisciplinary but less standardized than that of squamous cell carcinomas of the upper aerodigestive tract. As such, patients with sinonasal tumors can benefit from the expertise of the French expertise network for rare ENT cancers (Refcor). Knowledge of sinonasal tumour characteristics (histology, grade, risk of lymph node involvement, molecular characterization, type of surgery) is critical to the determination of target volumes. An update of multidisciplinary indications and recommendations for radiotherapy in terms of techniques, target volumes and radiotherapy fractionation of the French society of radiotherapy and oncology (SFRO) was reported in this manuscript.

[Vertebroplasty and kyphoplasty under dual guidance (CT and fluoroscopy): radiation dose to radiologist. A comparative study]. / Étude dosimétrique comparative de la vertébroplastie et de la kyphoplastie sous double guidage: scanner et fluoroscopique.

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.

[Posterior percutaneous arthrodesis under CT guidance after surgical anterior arthrodesis: a new technique]. / Arthrodèse percutanée postérieure sous guidage scanner en complément de l'arthrodèse antérieure chirurgicale: une nouvelle 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.

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.

Flap delineation guidelines in postoperative head and neck radiation therapy for head and neck cancers.

INTRODUCTION: Reconstructive surgery in head and neck cancers frequently involves the use of autologous flaps to improve functional outcomes. However, the literature suggests that postoperative radiotherapy deteriorates functional outcomes due to flap atrophy and fibrosis. Data on patterns of relapse after postoperative radiotherapy with a flap are lacking, resulting in heterogenous delineation of postoperative clinical target volumes (CTV). Flap delineation is unusual in routine practice and there are no guidelines on how to delineate flaps. Therefore, we aim to propose a guideline for flap delineation in head and neck cancers to assess dose-effects more accurately with respect to flaps. MATERIAL AND METHODS: Common flaps were selected. They were delineated by radiation oncologists and head and neck surgeons based on operative reports, on contrast-enhanced planning CTs and checked by a radiologist. Each flap was divided into its vascular pedicle and its soft tissue components (fat, fascia/ muscle, skin, bone). RESULTS: Delineation (body and pedicle) of Facial Artery Musculo-Mucosal, pectoralis, radial forearm, anterolateral thigh, fibula and scapula flaps was performed. Based on information provided in operative reports, i.e. tissue components, size and location, flaps can be identified. The various tissue components of each flap can be individualized to facilitate the delineation. CONCLUSION: This atlas could serve as a guide for the delineation of flaps and may serve to conduct studies evaluating dose-effects, geometric patterns of failure or functional outcomes after reconstructive surgery. Changes in postoperative CTV definitions might be needed to improve risk/benefit ratio in the future based on surgery-induced changes.

[Percutaneous brachial access: a few simple considerations]. / Abord brachial percutané: quelques règles simples.

This letter is with regards to the recently published article by Vidal et al. in the Journal Français de Radiologie Médicale. A clarification of US and venographic techniques of brachial venous catheterization and related complications are presented. The main indications for PICC line and subcutaneous port placement are described.

[Papillary thyroid microcarcinomas: review of 230 cases]. / Les microcarcinomes papillaires de la glande tyroïde: à propos de 230 cas.

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.

[Radiation-induced bronchiolitis obliterans with organizing pneumonia]. / Complications pulmonaires de la radiothérapie après cancer du sein : penser à la BOOP.

Bronchiolitis obliterans with organizing pneumonia is an inflammatory reaction that can occur as a consequence of various pulmonary affections. Radiotherapy is not the sole and systematic cause of bronchiolitis obliterans with organizing pneumonia. Radiation-induced should not be confused with post-radiation, dose-dependent, inflammatory pulmonary fibrosis, which is non-immunological and located within the irradiation field. The role of immunity, local inflammation and individual radiosensitivity in bronchiolitis obliterans with organizing pneumonia is not well defined. Bronchiolitis obliterans with organizing pneumonia represents 1% of irradiated patients with breast cancer. It results in fever (flu-like symptoms), a rather dry cough and dyspnea. In the post-radiation context, bronchiolitis obliterans with organizing pneumonia may be diagnosed several months and up to a year after breast irradiation. The treatment consists of prolonged steroids or immunosuppressants, which do not prevent chronicity in 15% of patients and death in up to 5% of cases, the remaining 80% of patients healing without sequelae.

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.

[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]. / Volumes cibles en radiothérapie des tumeurs de la tête et du cou Radiothérapie conformationnelle avec modulation d'intensité (RCMI) des carcinomes du cavum : aspects pratiques de la délinéation des volumes cibles et des organes critiques.

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.

Concomitant b.i.d. radiotherapy and chemotherapy with cisplatin and 5-fluorouracil in unresectable squamous-cell carcinoma of the pharynx: clinical and pharmacological data of a French multicenter phase II study.

PURPOSE: The aim of this phase II study conducted on unresectable squamous cell carcinoma (USCC) of the oro- and hypopharynx was to associate twice-a-day (b.i.d.) continuous nonaccelerated radiotherapy with concomitant cisplatin (CP)-5-fluorouracil (5-FU) chemotherapy, both given at full dose. Feasibility, efficacy, survival, and pharmacokinetic-pharmacodynamic relationships were analyzed. METHODS AND MATERIALS: Fifty-four consecutive patients with strictly USCC of oro- and/or hypopharynx received continuous b.i.d. radiotherapy (RT) (2 daily fractions of 1.2 Gy, 5 days a week, with a 6-h minimal interval between fractions). Total RT dose was 80.4 Gy on the oropharynx and 75.6 Gy on the hypopharynx. Three chemotherapy (CT) courses of CP-5-FU were given during RT at 21-day intervals (third not delivered after the end of RT). CP dose was 100 mg/m2 (day 1) and 5-FU was given as 5-day continuous infusion (day 2-day 6: 750 mg/m2/day cycle 1, 750 mg total dose/day cycle 2 and 3). Pharmacokinetics was performed for 5-FU (105 h follow-up) and CP (single sample at 16 h). Special attention was paid to supportive care. RESULTS: Good feasibility of RT was observed (85.2% of patients with total dose > 75 Gy). Five patients received 1 CT cycle, 34: 2 cycles, and 15: 3 cycles. The most frequent and severe acute toxicities were mucositis with grade 3-4 occurring in 28% at cycle 1 and 86% at cycle 2, as well as neutropenia (43% at cycle 2). Locoregional control at 6 months was observed in 66.7% of patients. No late toxicity above grade 2 RTOG was noticed. CP dose and 5-FU AUC(0-105h) were significantly linked to grade 3-4 neutropenia (cycle 2). Cumulative total platinum (Pt) concentration and Karnofsky index were the only independent predictors of locoregional control at 6 months. Finally, total RT dose and total Pt concentration were the only independent predictors of specific survival. CONCLUSION: This protocol showed good locoregional response with an acceptable toxicity profile. Pharmacokinetic survey is probably an effective approach to further reduce toxicity and improve efficacy. A multicentric randomized phase III study, now underway, should confirm these encouraging results.

Primary lung sarcomas: long survivors obtained with iterative complete surgery.

Primary lung sarcomas are uncommon histologic types of primary lung cancer and presents a wide spectrum of clinical behaviour. Nine patients treated at Antoine Lacassagne Cancer Center between 1982 and 1995 were studied. The median age was 63 years (range, 35-73 years) and the most common histologic types were malignant fibrous histiocytoma (four) and leiomyosarcoma (three). All of them underwent surgery, six patients had a complete surgery and three patients incomplete resections. The median overall survival for all patients was 36 months. In the subgroup of patients with initial complete resection, the median survival was significantly longer (47 months) than in the subgroup of patients with incomplete resection (6 months) (P<0.05, log-rank test). Moreover, two patients had a second complete resection for ipsilateral lung relapse and were long survivors (overall survival of 58 and 83 months, respectively). The ability to achieve a complete second surgery stress the possible benefit of an early detection of local recurrence. Because no specific symptom was linked with the local relapse, a systematic CT scan every 2 or 3 months could be required.

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.

Systematic ultrasonography in asymptomatic dense breasts.

The purpose of this study was to evaluate the role of ultrasonography in breast cancer screening. 350 Bilateral ultrasound (US) were performed in 350 asymptomatic patients with dense breasts. 7.5, 10 And 13 MHz transducers were used (Esaote Biomedica, Italy). In 185/350 patients, sonograms were normal, abnormalities were seen in 165/350: cysts (117), solid nodules (44) and mixed echogenicity nodules (4). All but two solid lesions were benign. Both malignant lesions were invasive carcinomas, 18 and 11 mm in diameter. In retrospect, they were palpable, but not visible on mammograms. Retroprospective review revealed that 24.7 of cysts and 31% solid nodules could be seen on mammograms. In 4 patients with fibroadenomas, US made a false positive diagnosis of breast cancer. Follow-up was obtained for 6 to 18 months in 45% of patients. Routine supplemental US evaluation for patients with mammographically dense breasts does not appear to significantly contribute to the accuracy of the work-up.