Effectiveness of modified radical neck dissection and postoperative radiotherapy.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the effectiveness of a modified radical neck dissection with preservation of non-lymphatic structures usually removed in advanced-stage head and neck epidermoid carcinoma associated with postoperative radiotherapy (PORT). METHODS: We analyzed retrospectively the files of 109 patients, presenting with epidermoid carcinoma of the upper digestive/respiratory tract staged N2 or N3, over a 6-year period. The rates of regional control, mortality, and recurrence were analyzed and linked to the kind of neck-dissection (usual radical neck dissection [RND], modified radical neck dissection [MRND], selective neck-dissection [SND]) performed. RESULTS: Forty-three neck dissections were RND, 92 were MRND, and 21 were SND. PORT was used in all cases. The mean follow-up was 57.3 months. The overall rate of regional control was 93.6% (97.7% for RND and 93.5% for MRND; p=0.35). Patients having undergone MRND had a better prognosis and less recurrence then patients having undergone RND (respectively p=0.007, and p=0.0004). DISCUSSION: MRND in association with PORT is an effective treatment in patients with advanced head and neck epidermoid carcinoma staged N2 and N3.

[Prognostic value of infiltration of squamous cell carcinoma of the floor of the mouth]. / Valeur pronostique de l'infiltration des carcinomes épidermoïdes du plancher buccal.

OBJECTIVE: The aim of this preliminary retrospective study was to evaluate the prognostic value of tumor thickness in squamous cell carcinoma of the floor of the mouth. MATERIALS AND METHODS: A total of 61 patients with previously untreated T1N0, T2N0 or T3N0 squamous cell carcinoma of the floor of the mouth were included in this preliminary study. An optical micrometer was used to determine the maximum of tumor thickness. We studied the relation between the overall survival at two and five years and tumor thickness. RESULTS: The cohort comprised 52 male and nine female patients. The mean and the median thickness were 7.2 and 6mm, respectively. Overall survival was 79.5 and 36.7% at two and five years, respectively. There was no significant association between thickness and overall survival (p=0.71) and between thickness and disease-free survival (p=0.63). CONCLUSION: The prognostic value of tumor thickness was not demonstrated in this preliminary study. We are currently conducting a study involving a larger patient population in our unit and we believe that tumor thickness should be considered in the management plan for patients with oral carcinoma.

[Role of PET-CT with 18-FDG in the management of UADT squamous-cell carcinomas: a retrospective study of 43 cases]. / Intérêt de la TEP-TDM au 18-FDG dans la prise en charge des cancers des VADS : étude rétrospective de 43 cas.

INTRODUCTION: The aim of our retrospective study was to evaluate the role of PET-CT in the management of upper-aerodigestive tract (UADT) squamous-cell carcinomas. MATERIAL AND METHODS: Our study included 43 patients with UADT squamous-cell carcinomas having undergone PET-CT for: initial staging (n=20), diagnosis of recurrent disease (n=16), and response to treatment (n=7). RESULTS: PET-CT diagnosed distant metastases missed by conventional imaging in four patients (20%) in initial staging, four patients (25%) in diagnosis of recurrent disease, and two patients (29%) in response to treatment. Overall, PET-CT induced a shift in the management of 10 patients (28%). DISCUSSION: Our study and other publications suggest that PET-CT should be used in: initial staging in Stage III and IV; detection of recurrent disease; and evaluation of treatment response.

[Simultaneous squamous cell carcinomas of the oral cavity and oropharynx]. / Carcinomes épidermoïdes simultanés de la cavité buccale et de l'oropharynx.

INTRODUCTION: Squamous cell carcinoma of the oral cavity is often a single localization, but the discovery of another or several associated lesions is not exceptional. The goal of our study was a retrospective analysis of patients having 2 simultaneous squamous cell carcinomas of the upper aerodigestive tract (UADT), i.e. diagnosed during the same panendoscopy by excluding the esophagus and the lung. PATIENTS AND METHODS: Between 1995 and 2001, 1,129 patients were treated for squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, and larynx in the Bordeaux Maxillo-facial Surgery Unit. 1% of these patients presented 2 simultaneous squamous cell carcinomas of UADT. RESULTS: Our series was divided in 9 men (75%) and 3 women (25%) with an average age of 61.3 years (48-86). At the end of the study 2 patients were lost to follow-up, 3 patients were alive without recurrence, and 1 patient was alive with recurrence. The average follow-up time was 17.6 months. DISCUSSION: A review of the literature gave an incidence of simultaneous squamous cell carcinomas of UADT varying from 1.3 to 12.8% according to authors. Thus, any patient having squamous cell carcinoma of the UADT must be considered as having an important potential risk to present another simultaneous cancer and to benefit from a systematic panendoscopy. In spite of an early diagnosis, the prognostic of these lesions remains bad.

[Treatment of squamous-cell carcinoma of the upper gum and the hard palate]. / Prise en charge du carcinome épidermoïde de la gencive supérieure et du palais dur.

PURPOSE: The aim of this retrospective study was to determine a rational of treatment of squamous-cell carcinoma of the upper gum and hard palate. PATIENTS AND METHOD: We analyzed retrospectively a series of 34 patients treated over a period of 11 years. RESULTS: There were 19 women (76%); mean age was 67.3 years; 76% had advanced tumors; 28% had neck nodes. The 5-year survival rate was 33.7%; patients without node involvement had better prognosis (p=0.034). The 5-year rate of recurrence-free survival was 61%; patients without node involvement had better prognosis (p = 0.032). At the end of the study, only 42% of patients were still alive. DISCUSSION: This type of tumor is different from those of other locations in the oral cavity or oropharynx. At the present time, surgery associated or not with post-operative radiotherapy seems to be optimal curative treatment. The question of whether neck dissection should be performed remains debated for patients without clinically nodes.

[Epidermoid carcinoma of oral cavity in patients less than twenty]. / Carcinomes épidermoïdes de la cavité buccale chez les sujets de moins de 20 ans.

OBJECTIVE: To analyze a review of literature of patients aged less than 20 years with epidermoid carcinoma of oral cavity. PATIENTS AND METHODS: Two sources were used to identify cases. A Medline search was performed as well as a review of our Medlog files where two cases of oral epidermoid carcinoma were identified in patients aged less than 20 years. RESULTS: Sixteen patients treated between 1981 and 2000 were included in this study. The mean age was 15.6 years and the sex ratio was 2.2 male/female. The mean time to diagnosis was 16.4 months. Tumors were staged III or IV in 71.4% of cases. The mean follow-up was 33.2 months. Rate of failure was 50% and one patient experienced local recurrence. At last follow-up, seven patients were alive with one patient living with cancer. All deaths resulted from the original cancer. DISCUSSION: This study illustrates the rarity of epidermoid carcinoma of the oral cavity in patients aged less than 20 years. Owing to the fact that most tumors were classified III or IV, time to diagnosis is probably the most important prognosis factor. Histological examination of all lesions of the oral cavity is required, irrespective of the age of the patient.

[Squamous-cell carcinoma of the tongue: treatment results and prognosis]. / Les carcinomes épidermoïdes de la langue. Résultats du traitement et pronostic.

OBJECTIVE: The aim of the study was to assess the results of curative treatment of patients with squamous cell carcinoma of the tongue and to evaluate survival and predictive factors of recurrence. PATIENTS AND METHODS: A series of 309 patients with squamous cell carcinoma of the tongue treated with curative intent was studied from January 1988 to December 1999. The percentage of oral tongue cancer was 82.2 and the percentage of cancer of base of the tongue was 17.8. Most patients underwent surgical procedure alone or combined with radiotherapy (92%). We performed 252 neck dissections. Bilateral dissections were performed for cancer of the apex linguae, cancer of the base of the tongue, for patients with N2c neck disease and whenever the primary tumor site crossed the median line. Twenty-five patients (8%) were treated with radiation therapy alone. Mean follow-up was 55 months. The functional results were assessed within a minimum of 10 months postoperative follow-up. RESULTS: In 45.2%, there was histological evidence of node invasion with 53.5% of extracapsular node spread in the neck specimens. Extracapsular node spread did not influence survival or recurrences. Occult cervical metastasis in an elective neck dissection in clinically negative necks was found in about 20% of patients with 47% of extracapsular node spread (41% for cancer of mobile tongue and 80% for those of base of the tongue). About 23% of patients with cancer of base of the tongue staged N0 had histological node invasion in controlateral neck nodes. The postoperative mortality rate was 0.9%. The rate of complications was 17%. The cancer recurred in 41.7% of all cases. Twelve percent of all patients had second primary cancers of the upper aerodigestive tract. The overall survival and non-recurrence rates at 2 and 5 years were higher in cancer of oral tongue than in cancer of base of the tongue. Survival rates were better when neck nodes were clinically or histologically negatives and in early-stage carcinomas. Non-recurrence rates were better when nodes were clinically or histologically negatives and when margins of exeresis were not involved. The functional results were better in oral tongue cancer than in base of the tongue cancer. DISCUSSION: Prognosis (survival and non-recurrence rates and functional results) of squamous cell carcinomas of oral tongue was better than prognosis of those of base of tongue. We recommend an aggressive surgical procedure even in patients with neck classed N0 (with reservations for T1 lesions with small depth of invasion): an ipsilateral supraomohyoid neck dissection for cancer of oral tongue and a bilateral supraomohyoid neck dissection for cancer of base of the tongue, cancer of oral tongue which crosses the median line of the oral cavity and cancer of the apex linguae. Postoperative radiotherapy must be performed when margins are positives and/or when nodes are involved with or without extracapsular spread.

[Surgical methods of removal of T4 nasopharyngeal malignancies. A preliminary report on 18 cases]. / Place de la chirurgie dans le traitement des cancers du cavum classés T4.

OBJECTIVES: To describe the technique and evaluate postoperative sequelae and results of transfacial surgical removal of T4N0 nasopharyngeal malignant neoplasms. MATERIAL AND METHODS: Eighteen cases of surgically-treated nasopharyngeal cancers, managed between january 1993 and october 2000, were retrospectively studied. Three patients were non-responders to neoadjuvant chemotherapy, 6 suffered local recurrence following standard treatment and 7 were operated first either because of a huge and osteolytic tumor or because of an uncommon histolopathology. RESULTS: Preoperative Vth nerve neuralgia (8 cases) was alleviated (4 cases) or cured (3 cases). At the time of diagnosis, ophthalmoplegia was observed in 3 cases. It disappeared postoperatively in 2 cases and after following radiation therapy in one. Median follow-up of the series was of 31.8 mths. Four patients were died of disease; one of them from distant metastases 4 years post-surgery. One patient is alive with distant metastases. The 13 last (72.2%) are alive without disease with a 35.6 mths median follow-up (6-77 mths). DISCUSSION: This short and heterogeneous series cannot lead to any evidence-based conclusion. But mid-term free-of-disease survival of 4 of the 5 patients suffering local recurrence and of patients presenting with so-called non-radiation-sensitive tumors is to be considered. In comparison with the high risk of neurological sequels following reirradiation, absence of specific toxicity of surgery observed in this series is to be underlined. CONCLUSION: In selected cases surgical treatment does not demonstrate any toxicity and is able to offer mid-term local control of the disease. Its role is to be evaluated further before inclusion in the therapeutic algorithm of these very bad prognosis-associated tumors.

[Conformal therapy of locally advanced cholangiocarcinoma of the main bile ducts]. / Radiothérapie conformationnelle des cholangiocarcinomes de la voie biliaire principale localement évolués.

PURPOSE: Retrospective study of 23 patients treated with conformal radiotherapy for a locally advanced bile duct carcinoma. PATIENTS AND METHODS: Eight cases were irradiated after a radical resection (R0), because they were N+; seven after microscopically incomplete resection (R1); seven were not resected (R2). A dose of 45 of 50 Gy was delivered, followed by a boost up to 60 Gy in R1 and R2 groups. Concomitant chemotherapy was given in 15 cases. RESULTS: Late toxicity included a stenosis of the duodenum, and one of the biliary anastomosis. Two patients died from cholangitis, the mechanism of which remains unclear. Five patients are in complete remission, six had a local relapse, four developed a peritoneal carcinosis, and six distant metastases. Actuarial survival rate is 75%, 28% and 7% at 1, 3 and 5 years, respectively (median: 16.5 months). Seven patients are still alive with a 4 to 70 months follow-up. Survival is similar in the 3 small subgroups. The poor local control among R0N+ cases might be related to the absence of a boost to the "tumor bed". In R1 patients, relapses were mainly distant metastases, whereas local and peritoneal recurrences predominated in R2. CONCLUSION: Conformal radiochemotherapy delivering 60 Gy represents a valuable palliative approach in locally advanced biliary carcinoma.

[Splenic vascular occlusion in the course of pancreatic cancer]. / Occlusions vasculaires spléniques au cours du cancer du pancréas.

INTRODUCTION: Pancreatic cancer is responsible for 6,000 deaths per year in France. During the course of the disease, venous thrombosis is common. Conversely, arterial thrombosis is rarely described. EXEGESIS: We report the case of a 59-year-old patient with pancreatic adenocarcinoma. Treatment by gemcitabine allowed rapid and persistent improvement of the body weight and a prolonged survival (18 months). Sudden complication, i.e. splenic arterial thrombosis, reversed the favorable outcome. CONCLUSION: Splenic venous thrombosis is a frequent complication occurring in the course of pancreatic cancer. It is easily diagnosed using abdominal computerized tomography. Arterial thrombosis is rarely observed. It might be due to either sporadic, unexpected, occurrence of cases related to the evolution of underlying pathological mechanisms, or to omitted treatment of vascular complications, as until the introduction of new anticancer drugs this disease was considered to be of very poor prognosis.

[Fractionated radiotherapy of intracranial meningiomas: 15 years' experience at the Bordeaux University Hospital Center]. / Radiothérapie fractionnée des méningiomes intracrâniens: 15 ans d'expérience au centre hospitalier universitaire de Bordeaux.

PURPOSE: To evaluate the long-term results of external fractionated radiation therapy (RT) in the treatment of intracranial meningiomas. PATIENTS AND METHODS: From January 1981 to December 1996, 156 patients with intracranial meningiomas were treated with external fractionated RT. Median age was 57. Indications for radiation therapy were as follows: (1) completely excised histologically aggressive tumors (12 patients); (2) incomplete surgical resection (37 patients); (3) medically inoperable or basilar tumors where operation would involve considerable danger or permanent neurological damage (77 patients); and, (4) tumor recurrences (30 patients). Most patients were irradiated with 6 to 9 MV photon beams. A three to four-field technique with coned-down portals was used. Since 1993, 71 patients had a three dimensional dosimetry. Doses were calculated on the 95% or 98% isodoses, all fields were treated every day, five days a week, for a median total dose of 50 Gy (1.8 Gy/Fraction). RESULTS: Median follow-up from radiation therapy was 40 months. Acute tolerance was excellent; an early clinical improvement during radiation therapy was noted in 19 patients (17.8%). Clinical improvement or stabilization was observed in 130 patients (83.4%). Radiologically, local control was obtained in 124 cases (79.4%) and tumor recurrences occurred in 21 cases (ten progressions in the treated volume, five borderline, six new locations). Overall and cause specific-survival rates were 75% and 89% at five years, and 45 and 76% at 10 years, respectively. CONCLUSION: These results reassess the role of fractionated RT in the treatment of intracranial meningiomas. Long-term tolerance is excellent for a majority of patients. The study of recurrences confirms the importance of the definition of the target volume, and asks questions about total given doses.

Prognostic value of histologic findings in neck dissections for squamous cell carcinoma.

BACKGROUND: Cervical node involvement is the most significant prognostic factor in head and neck squamous cell carcinoma. When histologic findings show node invasion, the number of positive nodes and the presence of extracapsular spread are commonly accepted as prognostic factors. OBJECTIVE: To confirm the findings of recent reports that there is no significant difference in outcome associated with extracapsular spread. SETTING: Referral center. DESIGN: Retrospective study. PATIENTS: Three hundred thirty-seven patients under-going 487 neck dissections for carcinoma of the oral cavity, oropharynx, hypopharynx, and larynx from January 1, 1985, to December 31, 1992. For N3 node involvement, a radical neck dissection was performed; other patients underwent supraomohyoid or functional neck dissection. Two hundred forty-two patients underwent postoperative radiotherapy (mean dose, 59 Gy). OUTCOME MEASURES: Survival capabilities calculated by the Kaplan-Meier method and significance calculated by the log rank test. RESULTS: Overall 5-year survival was 50.8%. The study of prognostic factors showed no significance for extracapsular spread (P = 45). Conversely, the number of positive nodes had a significant value (P < .001). CONCLUSIONS: Extracapsular node spread per se might be considered as no longer having a definitive prognostic value. These results, consistent with those of previous reports, may be due to wider use of combined treatment modalities.

[Practice of virtual simulation at the Saint-André hospital]. / Pratique de la simulation virtuelle à l'hôpital Saint-André.

PURPOSE: Prospective evaluation of a virtual simulation technique. PATIENTS AND METHODS: From September 1993 to February 1997, 343 patients underwent radiation therapy using this technique. Treated sites were mostly: brain (132), rectum (59), lung (43), and prostate (28). A CT-scan was performed on a patient in treatment position. Twenty-five to 70 jointive slices widely encompassed the treated volume. The target volume (CTV according to ICRU 50) and often critical organs were controured, slice by slice, by the radiation oncologist. Beams covering the CTV plus a security margin (PTV) were placed on the "virtual patient". Digital radiographs were reconstructed (DRR) as simulator radiographs for each field. Thus, the good coverage of PTV was assessed. Fields and beam arrangements were further optimized. Definitive isocenter was then placed using a classical simulator. Perfect matching of DRR and actual simulator radiographs had to be obtained. RESULTS: Nineteen patients presented grade 3, and 1 grade 4 acute radiation effects. With a median follow-up of 18 months, five patients suffered from grade 3, and one from grade 4 complications. Fifty-five patients had tumor recurrence in the treated volume, and 19 had marginal relapse. CONCLUSION: In our department, virtual simulation has become a routine technique of treatment planning for deep-seated tumors. This technique remains time-consuming for radiation oncologists: about 2 hours. But it stimulates reflexion on anatomy, tumor extension pathways, target volumes; and is becoming an excellent pedagogical tool.

[Post-radiotherapy cutaneous neuro-endocrine carcinoma]. / Carcinome neuro-endocrine cutané en zone irradiée.

INTRODUCTION: Merkel cell carcinoma or cutaneous neuroendocrine carcinoma is an uncommon severe disease. The carcinogenic effect of ionizing radiations has been suspected in exceptional observations. We report the sixth case of Merkel cell neuroendocrine carcinoma in a patient with prior radiotherapy. CASE REPORT: An 86-year-old man underwent radiotherapy for a basal cell carcinoma of the tip of the nose and developed a highly aggressive Merkel cell carcinoma at the same location 6 years later. DISCUSSION: The development of Merkel cell carcinoma on irradiated tissue accounts for 2.6 p. 100 of the 227 publications where dermatological history was reported. This percentage may be underestimated. The similar localizations of the irradiated zone and the site of cancer development 5 years later suggest that the Merkell cell carcinoma may be a radio-induced tumor. The delay may vary from 5 to 47 years. The similarity of the carcinogenic factors involved in Merkel cell carcinoma and squamous cell or basal cell carcinomas (ultraviolet, ionizing irradiation) and the frequent association of different types favor an epidermal origin for Merkel cell carcinoma. In clinical practice, past history of radiotherapy in an area where Merkell cell carcinoma develops indicates that therapeutic management must exclude post-operative radiotherapy.

[Routine use of electronic portal imaging. Positioning verification in 922 successive pelvic fields]. / Utilisation en routine du portal imaging électronique. Vérification de mise en place de 922 champs pelviens successifs.

Treatment reproducibility is a major criterion of quality assurance in radiation therapy. During each course, the same dose should be delivered in the same volume of irradiation. Today, portal imaging devices can be used routinely to check and correct patient positioning before much of the daily irradiation has been delivered. In this study we used the Portal Vision Varian (PVV) system during pelvic irradiation in 16 patients. This device can automatically acquire portal images in the first seconds of each course. Observed discrepancies are directly classified by the radiation oncologist according to their type (cranio-caudal, lateral, antero-posterior) and severity (correction of patient positioning is necessary or not). In case of error, patient positioning is corrected before the end of irradiation. Of the 922 portals analysed with PVV, 901 could be analysed (97%). Two hundred and ninety-nine positioning discrepancies were observed (33%) with 59 of them leading to correction (6%). Most of the time, these errors concerned antero-posterior portals. Finally, each patient had an average of 18 to 19 discrepancies which were mainly of no importance for treatment quality. Nevertheless, real errors leading to correction were observed in 14 patients (88%) with an average of four per patient. In some patients many errors occurred, while in others only a few. These shifts were not related to patient weight and thickness but probably a portal dimension. In summary, we think that during pelvic irradiation a portal imaging device should be used daily to improve treatment quality. This system can help the radiation oncologist to discover many positioning errors (an average of four) in the majority of patients (88%) and to correct them before the end of irradiation.

[Primary carcinoma of the parotid gland. A retrospective study of 31 cases]. / Carcinomes primitifs de la parotide. Etude rétrospective de 31 cas.

The medical records of 31 patients with histologically proven primary carcinoma of the parotid gland seen between January 1980 and December 1992 were reviewed. The efficiency of combined treatment both on locoregional control and overall survival was assessed. Twenty nine patients underwent extensive surgery and postoperative radiotherapy, two patients underwent extensive surgery alone. Locoregional control of disease at the end of treatment was achieved in 29 patients (94%). Eleven patients had recurrences. For the complete series the overall two and five-year survival rates were 73% and 46% respectively. Even in case of locoregional control with combined treatment, overall survival rates are low because of distant metastases.

Superior vena cava thrombosis related to catheter malposition in cancer chemotherapy given through implanted ports.

BACKGROUND: Thrombosis of the central veins is one of the most frequent complications of implanted venous access devices. Among the first cases occurring in our patients, most were associated with left-sided placement of the ports, with catheter tips lying against the external wall in the upper half of the superior vena cava. Some chest radiographs showed lateromediastinal opacities centered on the catheter tip, suggesting a vessel injury. This position allows a narrow contact between the catheter tip and the vessel wall, thus endothelial injuries might result from mechanical and chemical attack. METHODS: To assess the role of catheter position, we reviewed the routine chest radiographs of 379 patients who received chemotherapy through venous access devices and were followed up at our department between December 1985 and December 1990. Four groups (upper left, upper right, lower left, and lower right) were defined according to the level of the catheter tip (innominate veins or upper half of the vena cava versus lower half of the vena cava or auricula) and to the side of port implantation. RESULTS: Ten patients developed symptomatic venous thrombosis (superior vena cava in 9 patient, left subclavian vein in 1 patient). A strong correlation existed between catheter position and incidence of thrombosis: upper left, 8/28 (28.6%); upper right, 1/33 (3%); lower right, 1/68 (1.5%); and lower left, 0/250. Since 1988, we have insisted on replacement of malpositioned catheters, and we have observed fewer thromboses (2/191 versus 8/188). CONCLUSIONS: The current study suggests that patients with left-sided ports and catheter tips lying in the upper part of the vena cava are at high risk for severe thrombotic complications.

[Titanium plates for mandibular reconstruction and radiotherapy]. / Plaques de reconstruction mandibulaire en titane et radiothérapie.

Mandibular reconstruction plates are now used after cancer surgery in particular patients. This study assesses the irradiation of Titanium mandibular reconstruction plates in terms of both dosimetry and mid-term tolerance. Twenty patients with mandibular plates underwent radiotherapy (mean dose 60 Gy). The radiation dose on the patient itself was calculated with 3-dimensional treatment planning. A clinical and radiological evaluation of tolerance was made 6 months after the end of the treatment: intraoral and cutaneous healing and possible osteomyelitis. Mid-term tolerance was very satisfactory with only two failures at 6 months. When using parallel opposing fields, the overdosage into tissues was reduced to approximately 5 p. cent; and radiotherapy has probably no effect on titanium plate tolerance.