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.

[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.

Management of choroidal metastases.

BACKGROUND: Choroidal metastases (CM) are the most common malignant intraocular lesion observed in up to 4-12% of necropsy series of patients with solid cancer. The spectrum of presentations varies from prevalent CM in disseminated cancer to isolated CM. CM are responsible for visual deterioration. Depending on the primary cancer, estimated life expectancy, overall cancer presentation and ocular symptoms, the management of CM varies widely. We address the multidisciplinary management of CM and technical aspects of radiotherapy. MATERIAL AND METHODS: A systematic review of literature was performed from 1974 to 2014. RESULTS: Choroidal metastases occur preferentially in breast and lung carcinomas but are reported in all cancer types. The standard treatment remains external beam radiotherapy, applying 30Gy in 10 fractions or 40Gy in 20 fractions. The reported complete response and improved visual acuity rates are 80% and 57% to 89%, respectively. Some chemotherapy or new targeted therapy regimens yield promising CM response rates. DISCUSSION: Radiation therapy consistently shows rapid symptom alleviation, yield excellent local control and functional outcomes. However, there are only few reports on late toxicities after 6months given the unfavorable prognostic of CM patients. Selected patients may live more than two years, underlying the need to better assess mean and long term outcomes. Some authors have favored exclusive systemic strategies with omission of irradiation. The current literature suffers from the scarcity of prospective trials. Duration of tumor response following systemic therapy is rarely reported but appears less favorable as compared to radiotherapy. Systemic treatments may be proposed for pauci-symptomatic CM in a polymetastatic context while radiation therapy remains necessary in symptomatic CM either upfront or as an alternating treatment. Focalized radiation like brachytherapy and proton therapy may be proposed for isolated CM with long disease-free interval between primary and CM, as these techniques have the potential to yield better tumor and functional outcomes in patients with long life expectancy.

[Non-targeted effects (bystander, abscopal) of external beam radiation therapy: an overview for the clinician]. / Effets non ciblés (bystander, abscopal) de la radiothérapie externe : potentielles implications pour le clinicien ?

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

[Radiation therapy for pleomorphic adenoma of the parotid]. / Adénomes pléomorphes parotidiens récidivants : place de la radiothérapie.

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

[Radiation therapy in thyroid cancer]. / Place de la radiothérapie externe dans les cancers de la thyroïde.

Anaplastic thyroid cancers represent 1-2% of all thyroid tumours and are of very poor prognosis even with multimodality treatment including external beam radiation therapy. Conversely, differentiated thyroid carcinomas (at least 80% of thyroid cancers) hamper good prognosis with surgery with or without radioiodine and there is hardly any room for external beam radiation therapy. Insular and medullar carcinomas have intermediary prognosis and are rarely irradiated. We aimed to update recommendations for external beam irradiation in these different clinical situations and put in light the benefits of new irradiations techniques. A search of the French and English literature was performed using the following keywords: thyroid carcinoma, anaplastic, chemoradiation, radiation therapy, surgery, histology and prognostic. Non-mutilating surgery (often limited to debulking) followed by systematic external beam radiation therapy is the standard of care in anaplastic thyroid cancers (hyperfractionated-accelerated radiation therapy with low-dose weekly doxorubicin with or without cisplatin if possible). Given anaplastic thyroid cancers' median survival of 10 months or less, neoadjuvant and adjuvant chemotherapy may also be discussed. Ten-year survival rates for patients with papillary, follicular and Hürthle-cell carcinomas are 93%, 85%, and 76%, respectively. Massive primary incompletely resected iodine-negative disease indicates external beam radiation therapy. Older age (45 or 60-year-old), poor-prognosis histological variants (including tall cell cancers) and insular cancers are increasingly reported as criteria for external beam radiation therapy. Massive extracapsular incompletely resected nodal medullary disease suggests external beam radiation therapy. Radiation therapy morbidity has been an important limitation. However, intensity modulated radiation therapy (IMRT) offers clear dosimetric advantages on tumour coverage and organ sparing, reducing late toxicities to less than 5%. The role of radiation therapy is evolving for anaplastic thyroid cancers using multimodal strategies and new chemotherapy molecules, and for differentiated cancers using minor criteria, such as histological variants, with IMRT becoming a standard of care.

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

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

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

OBJECTIVE: The primary objective of this study was to determine the clinical and pathological prognostic factors in locally advanced oral cavity cancers treated by primary surgery. METHODS: All patients treated by primary surgery with free-flap reconstruction for locally advanced oral cavity squamous cell carcinoma in our institution between 2000 and 2010 were included in this retrospective study. Overall, cause-specific and locoregional disease-free survivals were determined by Kaplan-Meier analyses. Clinical and histological prognostic factors were assessed by univariate (Log Rank tests) and multivariate (Cox models) analyses. RESULTS: A total of 149 patients (102 men and 47 women; mean age=61.3±12.1 years) were included in the study. Five-year overall, cause-specific and locoregional disease-free survivals were 55%, 68% and 71%, respectively. Age, comorbidity and tumour size (histological evaluation) were significantly correlated with overall survival (P<0.05). Age, tumour size, bone invasion and surgical margins were significantly correlated with locoregional disease-free survival (P<0.05). CONCLUSION: The main prognostic factors identified in this study were clinical (age and comorbidity) and histological (pathological tumour size, bone invasion and surgical margins).

Percutaneous cementoplasty for the treatment of extraspinal painful bone lesion, a prospective study.

PURPOSE: The current gold standard treatment of localized painful bone lesion is radiotherapy but this technique has limitations. Our study aims to demonstrate that cementoplasty is an efficient alternative for these palliatives indications when lesions involve extraspinal bones. We prospectively followed 20 patients who received a percutaneous cementoplasty on painful lytic bone lesions between May 2008 and May 2010. MATERIALS: Seventeen patients also had difficulty walking in relation to the pain experienced. The clinical indication for treatment was severe pain (≥4 on the numeric scale) due to bone lesion on CT or MRI. All procedures (except one) were performed under local anesthesia. RESULTS: Feasibility was 100% without immediate complications. The patients experienced a significant and rapid decrease of their pain (4.1 points, P<000.1) and this effect was sustained over the long term (7.75 months of follow-up on average). Sixty-four percent of patients treated on the lower limbs and pelvis improved mobility. CONCLUSION: In our experience, percutaneous cementoplasty may be a safe and effective palliative treatment for localized painful lytic lesion. Combining CT and fluoroscopic guidance seems to be the safer option because of extravertebral localization. Smart fill of the bone and careful selection of patient determine the effectiveness of the procedure. Diffuse painful lesions and long bone diaphysis should not be good indications.

[Oligometastatic bone disease. Can limited metastatic bone disease be cured? Is there room for local ablative treatments?]. / Traitement local ablatif de la maladie oligométastatique osseuse (hors chirurgie).

Solitary metastases have been reported in up to 30% of cases in imaging series. Local treatment aims at consolidating the injured bone and to prevent neurologic complications. Since the prognosis of bony metastatic disease is about 30 months and includes some long survivors, the multisdisciplinary committee in charge of the patient should ask the question and decide on the type of radical/ablative intervention in case of oligometastases. A literature search was performed using MESH terms (bone, metastases, radiotherapy, radiology, cement, radiofrequency ablation, chemoembolisation). Local ablative treatments can yield symptomatic relief and local control rates of about 90%. Stereotactic hypofractionated irradiation and cementoplasty are increasingly used. In conclusion, local ablative treatment of bony oligometastases is an efficient treatment. Its potential impact on survival remains to be demonstrated prospectively in clinical trials.

Radio-anatomy of the superior vena cava syndrome and therapeutic orientations.

Superior vena cava syndrome (SVCS) groups all the signs secondary to the obstruction of superior vena cava drainage and the increase in the venous pressure in the territories upstream. There are two major causes of SVCS: malignant, dominated by bronchopulmonary cancer, and benign, often secondary to the presence of poorly positioned implantable venous devices. CT scan is the key examination for the exploration of SVCS. It specifies the characteristics of the stenosis, its aetiology and detects collateral venous routes. Scannography reconstructions provide a true map of the obstacle, indispensable in planning the endovascular treatment.

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

OBJECTIVE: The objective of this study was to evaluate the prognostic impact of tumour multifocality in papillary thyroid microcarcinoma (PTMC). METHODS: All patients who underwent total thyroidectomy and central neck dissection for PTMC in our institution between 1990 and 2007 were included in this retrospective study. Statistical correlations between tumour multifocality and various clinical or pathological prognostic parameters were assessed by univariate and multivariate analyses. RESULTS: A total of 160 patients (133 women and 27 men; mean age: 47.8±13.7 years) were included in this study. Tumour multifocality was demonstrated in 59 (37%) patients. Central neck metastatic lymph node involvement was identified in 46 (28%) patients. No statistical correlation was demonstrated between tumour multifocality and the following factors: age, gender, tumour size, extension beyond the thyroid, metastatic central neck lymph node involvement and risk of recurrence. A tumour diameter greater than 5mm was associated with a higher risk of recurrence (P=0.008). CONCLUSION: Tumour multifocality does not appear to have a prognostic impact in PTMC.

Radiotherapy and radiology: joint efforts for modern radiation planning and practice.

With new irradiation techniques, the dose can be better matched to the contours of the tumour. The corollary is that greater precision is required. Recent intercomparison studies of treatment plans have emphasized the need to harmonise contouring practices. More of a consensus approach is based on using adaptive imaging modalities, expert group recommendations and automatic segmentation atlases, on harmonisation of dosimetric decisions through employing exhaustive nomograms for organs at risk, and on indexes for choosing optimal treatment plans. On another level, quality assurance and data pooling programmes have been set up, making use of DICOM-RT data transfer (image networks). The combination of several irradiation techniques (for example, intensity-modulated conformal radiation therapy plus CyberKnife(®) boost and re-irradiation), making it possible to irradiate tumours better, requires the cumulative doses to be recorded by dose summation software. Real awareness has been achieved in recent years as regards improving the quality of treatment, pooling data and harmonising practices.

Imaging of intervertebral disc prostheses.

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