[Case report forum: the example of French sarcoma group multidisciplinary discussion tools. Sarcomes de la FNCLCC]. / Forum de discussion de cas clinique: exemple de la concertation pluridisciplinaire web du groupe Sarcomes de la FNCLCC.

Within the Rubis 4th framework of European project is led a pilot experiment of tools and services for health professionals in prospect for the Aquitanian healthcare network. The sarcoma group of the FNCLCC (47 people) uses on its web site a multidisciplinary dialogue with a specific discussion forum. This service allows the anonymous publication of a imaging clinical case and to start a take care discussion. 87 cases were published in 13 months involving 261 answers from February 1999 to February 2000. A case is published every 4 days on average and the deadlines for replies regularly drop (15 days in February 1999 down 1.1 day in February 2000). The cases are published either for a diagnosis or treatment request (30%) or for the physical preparation of meeting or for the continuous medical training (70%). There are many advantages in comparison with the other possibilities of discussion: availability, autonomy of publication, cost, number of experts participating. These NTIC services will be developing within the regional healthcare oncology networks and are already tested by other regional groups (Lymphoma) considering the simplicity of use, management and training of the functionality.

Outcome of squamous cell carcinoma of the gingiva: a follow-up study of 83 cases.

BACKGROUND: Squamous cell carcinomas of the gingiva are relatively rare tumours. Standard treatment is based on surgery and radiotherapy. The extent of bone involvement affects mandibulectary indications. PURPOSE: A retrospective review of squamous cell carcinomas of the gingiva was performed to evaluate the incidence of mandibular or maxillary bone involvement. Indications for marginal and segmental bone resections are specified. MATERIAL: From 1985 to 1996, 83 patients with squamous cell carcinoma of the gingiva were treated at the Department of Surgery (Institut Bergonié, Bordeaux, France) and at the Department of Maxillofacial and Plastic Surgery (Centre Hospitalier Universitaire, Bordeaux, France). Forty-three underwent surgery plus postoperative radiotherapy. Twenty-two had flap reconstructions. Clinical evaluation and panorex roentgenography were the means used to evaluate bony invasion and to decide on the extent of bone resection. METHODS: A retrospective review of 83 consecutive patients was performed. This series is unusual in its homogeneity: surgery was performed by only two individuals and the radiotherapy was the responsibility of just two physicians. Outcome was calculated using the Kaplan-Meier method. RESULTS: Primary local control was achieved in 72 patients (87%). Overall survival and rate of recurrence were comparable to those of other squamous cell carcinomas of the oral cavity and oropharynx. CONCLUSION: Surgical resection continues to be the mainstay of treatment and this study tends to confirm the validity of modified neck dissection and marginal bone resection in suitably selected patients.

Supraomohyoid neck dissection in cancer of the oral cavity.

BACKGROUND: In oral cavity cancer, supraomohyoid neck dissection (SOHND) is becoming more popular for patients with N0 and N1 disease in the neck. The aim of this study was to assess the value of this surgical procedure. METHODS: The study included 237 previously untreated patients with oral cavity cancer. The neck treatment consisted of SOHND or functional neck dissection (FND). One hundred sixty patients underwent postoperative radiation therapy. Survival probabilities, neck recurrences, and distant metastases were analyzed according to the surgical procedure. RESULTS: For patients having undergone SOHND, the 5-year survival probabilities were 70.2% and 76.5% in N0 and N1 necks, respectively. The neck recurrence rate in SOHND was 2%. CONCLUSIONS: SOHND is an effective method of treatment for the clinically negative neck in patients with squamous cell carcinoma of the oral cavity. It also proves efficient, in conjunction with postoperative radiotherapy, for control of neck metastases in selected patients.

[Standards, options and recommendations (SOR) for clinical care of squamous cell carcinoma of the oropharynx. Groupe de travail SOR]. / Standards, Options et Recommandations pour la prise en charge des patients atteints de cancer épidermoïde de l'oropharynx.

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres 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 outcome for cancer patients. The methodology is based on literature systematic review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. OBJECTIVES: To develop clinical practice guidelines according to the definitions of Standards, Options and Recommendations for the management of squamous carcinoma of the oropharynx. METHODS: Data have been identified by literature search using Medline (1991-1998) and the expert groups personal reference lists. Once the guidelines were defined, the document was submitted for review to national and international independent reviewers and to the medical committees of the 20 French Cancer Centres. RESULTS: The main recommendations for squamous cell carcinoma of the oropharynx management are that: 1) diagnosis and initial assessment should be based on appropriate clinical and radiological findings; 2) the therapeutic strategy is based on surgery, radiotherapy, bradytherapy and chemotherapy; 3) in limited tumours, the recommended strategy involved the use of one of these modality; 4) a multimodality approach is recommended for the treatment of extended resectable tumours. Following results of recent meta-analyses, use of neo-adjuvant chemotherapy is not recommended. The same studies have shown that association of chemotherapy and radiotherapy either in sequence or in combination significantly improve survival of extended curable tumours. These associations are recommended within the framework of clinical trials; 5) follow-up of squamous carcinoma of the oropharynx should involve physical examination of the upper aerodigestive tract and the lymph nodes areas every three months during the first year, every six months during the second year and then every year. An annual chest x-ray is recommended. Other investigations should be performed as indicated by symptoms and clinical manifestations.

[Internet: importance in cancerology and practical connection sites]. / Internet: intérêt en cancérologie et modalités pratiques de connexion.

There has been a considerable increase in World Wide Websites on the Internet on medicine and oncology. The clinician has access to an abundance of useful documentary and graphic information. The challenge is firstly to find a relevant site and then to evaluate the quality of the material available on that site. In future, there may well be a service on the network which reviews sites. The aim of this paper is to give practical guidance to connecting on the Internet as well as a list of the best sites for clinicians, researchers, students and oncologists.

A web interface for multimedia electronic patient record: consensual validation of the Aquitaine Health Information Network prototypes.

The PromptPR patient record originates from the research and development project DILEMMA (1992-94) and has been undertaken in the context of the research project PROMPT (4th Framework Health Telematics). Here we present the work undertaken with the doctors of the project RISA (Réseau d'Information de Santé en Aquitaine) in order to adapt the patient record to their various practical medical conditions. Effectively, there are implications for general practitioners, the private sector and hospital personnel. The richness of the workgroup and the adoption of a participative methodology, guided by the demands of the end-users allowed the creation of an electronic patient record (EPR) sufficiently simple and generic as to serve as a common base for both general practitioners and hospital medical staff. Independent of this system, the multimedia interface presented is based on frames, which enables visualization of the EPR either vertically or horizontally, with access to both the multimedia and external documentation of the patient. This web interface is the result of a consensus of opinion within the group.

[Standards, options and diagnostic and therapeutic recommendations in oncology. Fédération Nationale des Centres de Lutte contre le Cancer]. / Standards, options et recommandations diagnostiques et thérapeutiques en cancérologie. Fédération Nationale des Centres de Lutte contre le Cancer.

From 1992 onwards, the various French institutions working on cancerology launched a program for establishing standards and options in view of assisting practitioners. The program is basically oriented towards diagnostics and care, but economic, social or ethical aspects are not neglected. A first edition of the recommended standards and options was published in 1995 on paper and CD-ROM. Dissemination through Internet is planned.

[Prognosis of epidermoid carcinoma of oropharyngeolaryngeal region]. / Pronostic des carcinomes épidermoïdes oro-pharyngo-laryngés.

Knowledge of pronostic factors is essential for assessment of therapeutic procedures and for individual treatment selection and adjustment for patient with squamous cell carcinomas of the head and neck. This paper reviews known clinical, histological and biological prognostic factors and their prognostic significance in predicting survival, response to treatment and locoregional and distant recurrences. Most significant criteria include tumor site and extension, absence or presence of cervical lymph nodes and their location, size and mobility. Histological, disease-related factors include number and location of involved nodes, and extra-capsular spread, which is the most significant independent factor. Response to treatment is an essential factor which should be used to alter or complement the treatment plan. Other treatment-related factors include technical parameters that can impact the outcomes and should be taken into account when assessing treatment procedures. Preliminary studies suggest that biological factors may be used as efficient predictors within the next few years but they are still under evaluation and therefore are not to be used in routine practice. They are expected to improve prediction of response to radiotherapy and chemotherapy as well as prediction of the risk of distant metastases and of metachronous head and neck cancers.

[Quality control of care in a surgical department. Experience of the Fondation Berganié]. / Contrôle de la qualité des soins dans un service de chirurgie. Expérience de la Fondation Bergonié.

Activity in a surgical department can be evaluated quantitatively, but is should also be assessed qualitatively. One way to control the quality of care is to determine as accurately as possible the incidence of pre- peri- and post-operative complications and to analyse these date in a critical comparative study. This was accomplished in the surgical department of the Fondation Bergonié, Bordeaux during three test periods over the last five years--March 1987 (127 patients), June-July 1989 (276 patients), and June 1991 (147 patients). Results of this analysis cannot validly be compared with those of other departments with different patient recruitment and activity functions. However, this study within a department with regular, homogeneous activity did demonstrate, over a period of several years, a clear reduction in operative mortality, essentially by improved control of infectious complications by the extensive use of prophylactic antibiotic therapy for all surgery with a septic risk or for debilitated patients. Results also demonstrated the low cost effectiveness of routine pre-operative exploratory examinations.

[Symptomatic treatment of pain in cervico-facial cancers]. / Traitement symptomatique des douleurs des cancers cervico-faciaux.

Pain is frequent in patients presenting cervico-facial cancers. It can be acute or persistent, or present at the morbid entity known as chronic pain. The specific anatomical site and the often poor environment explain that the physical disability related to pain is increased by multiple psychosocial problems. Multidisciplinary care management by several actors is required and can be facilitated by a simple decision-making model. The schema presented can be used to prompt discussion and criticism. It needs constant improvement and extensions in order to reach a consensual attitude towards this king of suffering but also towards other situations of pain care management frequently encountered in cancer patients as well as those with other pathologies.

[Treatment of cervical lymph nodes in lip cancers]. / Traitement des aires ganglionnaires cervicales dans les cancers des lèvres.

From 1970 to 1985, 299 patients with lip cancer were examined, treated and followed-up at the Bergonié Foundation. In most cases, interstitial radiotherapy was used and the local control rate reached 94%. Local recurrences could usually be treated again, so that the final local control rate was 99%. However, the management of neck nodes remains controversial in some cases: 5.6% only of T1-2 N0 stages developed neck nodes, which were successfully controlled in 78.9% of cases and it was therefore considered that the preferred option should be to maintain the patients under close follow-up. For T3 N0 cases, of which 17.6% would evolve, it was considered that a sub-mental and sub-maxillary neck node dissection was advisable when performance status was satisfactory and when a close follow-up was difficult. The recurrence rate was 40% for patients with palpable neck nodes who were often submitted to a combined radio-surgical treatment. In such cases, recurrences were controlled in 22% of patients who died 7 times out of nine.

[Home parenteral nutrition in oncology, a information project]. / Nutrición parenteral domiciliaria en oncología, proyecto de informatización.

The increase in the indications for total parenteral nutrition (TPN) of long or medium term duration led to an investigation on a discontinued method during the night. The patient was thus free during the daytime. Cyclic parenteral nutrition (CPN) at home is a comfortable solution. Parenteral nutrition at home (PNH) enables the quality of life to be improved and also reduces the cost of the therapy, which may permit us to establish a structure for oncological patients to take advantage of PNH. In the specific case of oncology, we shall examine in the first place, the conditions, indications and counter indications, complications, advantages and structure operation. To improve on this method, we have introduced a data processing system that provides the doctor with more autonomy and assists in caring for the patient and in the therapeutical decision.

[Contribution of the combination of radiation and surgery in the treatment of invasive pharyngo-laryngeal carcinoma]. / L'apport de l'association radio-chirurgicale dans le traitement des carcinomes pharyngo-laryngés infiltrants.

On the basis of the retrospective analysis of 269 cases of pharyngo-laryngeal carcinoma, the authors recall that the degree of tumour invasion is one of the essential prognostic factors for this disease. The macroscopic appearance of the tumour should therefore play a determinant role in the choice of treatment, as invasive lesions are generally responsive to radiotherapy.

[Conservative axillary curettage in the treatment of operable breast cancers]. / Le curage axillaire conservateur dans le traitement des cancers du sein opérables.

Functional motor and sensory sequelae of conservative or non-conservative treatment of breast cancer are due essentially to axillary curettage, during which the nerve branches crossing the axillary pyramid are often sectioned. Analysis of axillary glands is now fundamental for determination of prognosis and adjuvant treatment required. The present report demonstrates that knowledge of the glandular state can be obtained, while limiting functional sequelae, by careful dissection of axilla avoiding all nervous elements (motor nerves of latissimus dorsi, serratus anterior and pectorals, perforating intercostal sensory nerves) and the must important vascular structures (inferior scapula pedicle and pedicle of pectoral muscles.

[Approach to therapeutic risk by study of operative mortality. From 102 postoperative deaths between 1975 and 1984 at the Fondation Bergonié]. / Approche du risque thérapeutique par l'étude de la mortalité opératoire. A partir de 102 décès post-opératoires survenus en 10 ans (1975-1984) à la Fondation Bergonié.

A retrospective analysis of operative mortality in the cancer surgery department of the Fondation Bergonié between 1975 and 1984 allowed priority objectives to be defined requiring maximum efforts of the treating team. During this decade, 18,582 patients underwent surgery; 15,794 "first hand" operations were for cases not previously treated. Amongst the latter, 102 died within 90 days of surgery, 45 due to multifocal or apparently isolated pulmonary infection and 57 without any known infectious context. Separating patients into two groups: periods 1975-1979 and 1980-1984, demonstrated a notable decrease in postoperative mortality from 68 to 34. This improvement was due mainly to a reduction in deaths from infection (from 37 to 8 patients in the period 1980-1984). This marked improvement was probably the result of various combined causes: Mastery of parenteral nutrition enabling patients to be operated upon in better condition, or to tolerate possible complications better; Use of routine antibiotic therapy before surgery to digestive tube or ORL regions. These encouraging result suggest the need for enlargement of indications for routine prophylactic antibiotic therapy.

[Development of a knowledge-based system for aiding therapeutic decision in breast cancer]. / Développement d'un système à base de connaissances pour l'aide à la décision thérapeutique dans les cancers du sein.

The SENEX project has been initiated at the fondation Bergonié in 1985 and is intended for providing physicians in general hospitals with knowledge based systems for the management of cancer treatment protocols. The design and building of a knowledge-based system for the management of breast cancer protocols (SENEX) was the first goal of this project. SENEX has been developed using a commercially available development tool (Personal Consultant Plus, Texas-instruments) derived from EMYCIN. It runs on IBM and compatible microcomputers. The knowledge base embeds the formal knowledge contained in the breast cancer protocols currently in use at the fondation Bergonié, and some judgmental knowledge acquired form breast cancer experts. Production rules and frames allowed us to adequately represent and structure this knowledge and the problem solving processes related to the management of breast cancer. A preliminary informal evaluation of the system has shown that it performs at the expert-level in giving advice for patients included in formal protocols. Its use and acceptability are good. However, we have to add judgmental knowledge into the knowledge base and to interface the system with a temporal data base management system to improve the overall performances of SENEX. Moreover the effectiveness of the system remains to be demonstrated before one can anticipate is routine use in clinical practice.

[Immediate repair of urethroperineal fistulas after abdominoperineal amputation by means of a cutaneo-muscular flap of the gluteus maximus. Apropos of 2 successfully treated cases]. / Réparation immédiate des fistules uréthropérinéales après amputation abdominopérinéale à l'aide d'un lambeau cutanéo-musculaire du grand fessier. A propos de 2 cas traités avec succès.

Although a rare complication, the development of a urethro-perineal urinary fistula immediately after abdomino-perineal amputation is a difficult problem to solve. The fragility of the membranous urethra immediately in contact with the exenterated pelvic cavity which takes several weeks to fill in makes any attempt at isolated direct suture very hazardous. Secondary repair is also frequently difficult and the "functional prognosis is far from being always favourable". The major handicap resulting from the perpetuation of this type of fistula has led us to propose an attempt at immediate repair as soon as it is diagnosed with filling of the pelvi-perineal cavity by a cutaneo-muscular flap taken from gluteus maximus. In the two cases in which this treatment was performed, the fistula was cured and a good quality functional result was obtained.