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International audience; We present the update of the recommendations of the French society of oncological radiotherapy on radiotherapy of laryngeal cancers. Intensity modulated radiotherapy is the standard of care radiotherapy for the management of laryngeal cancers. Early stage T1 or T2 tumours can be treated either by radiotherapy or conservative surgery. For tumours requiring total laryngectomy (T2 or T3), an organ preservation strategy by either induction chemotherapy followed by radiotherapy or chemoradiotherapy with cisplatin is recommended. For T4 tumours, a total laryngectomy followed by radiotherapy is recommended when feasible. Dose regimens for definitive and postoperative radiotherapy are detailed in this article, as well as the selection and delineation of tumour and lymph node target volumes.

International audience; Nasopharyngeal cancers are a rarity in France. Radiotherapy is the cornerstone of treatment, frequently combined with chemotherapy. The technical modality of radiotherapy is complex in this disease, which is located in the vicinity of numerous organs at risk. In this article, we will present the updated guidelines of the French society for radiation oncology (Société française de radiothérapie oncologique, SFRO) on the indications, and technical details of radiotherapy in nasopharyngeal cancers.

International audience; We present the updated recommendations of the French Society for Radiation Oncology on benign intracranial tumours. Most of them are meningiomas, vestibular schwannomas, pituitary adenomas, craniopharyngiomas, and glomus tumours. Some grow very slowly, and can be observed without specific treatment, especially if they are asymptomatic. Symptomatic or growing tumours are treated by surgery, which is the reference treatment. When surgery is not possible, due to the location of the lesion, or general conditions, radiotherapy can be applied, as it is if there is a postoperative growing residual tumour, or a local relapse. Indications have to be discussed at a multidisciplinary panel, with precise evaluation of the benefit and risks of the treatments. The techniques to be used are the most modern ones, as multimodal imaging and image-guided radiation therapy. Stereotactic treatments, using fractionated or single doses depending on the size or the location of the tumours, are commonly realized, to avoid as much a possible the occurrence of late side effects.

This article aims to describe and list the clinical trials that have changed our practices in breast cancer, urological cancer, gynecological cancer, cancer of the upper aerodigestive tract and digestive cancer in the last ten years.We listed and selected the studies published between 2010 and 2020. The articles were identified on the basis of a Medline search with PubMed and knowledge of the authors.Five to six trials were selected in breast cancer, urological cancers, gynecological cancers, cancers of the upper aerodigestive tract and digestive cancers asking the different fundamental questions in radiotherapy.Depending on the pathologies, the questions raised over the past 10 years remain fundamental questions such as the place of neoadjuvant treatment, the place of hypofractionation or the type of chemotherapy concomitant with radiotherapy.

Cholangiocarcinomas are digestive tumors whose incidence remains low and have poor prognosis. The benefits of adjuvant radiochemotherapy and radiotherapy have never been demonstrated in any phase III randomized controlled trial. Chemotherapy with capecitabine 6 months is the standard of care in adjuvant setting. Radiochemotherapy is validated in R1 patients. It is not recommended in neoadjuvant situations given the lack of evidence. Chemotherapy and radiochemotherapy are validated in adjuvant or locally advanced diseases. Stereotactic radiation therapy offers an interesting perspective, at the cost of significant digestive toxicities, requiring evaluation in randomized trials.

It is proposed to delineate the anatomo-clinical target volumes of primary tumor (CTV-P) in ethmoid cancers treated with post-operative radiotherapy. This concept is based on the use of radioanatomy and the natural history of cancer. It is supported by the repositioning of the planning scanner with preoperative imaging for the replacement of the initial GTV and the creation of margins around it extended to the microscopic risk zones according to the anatomical concept. This article does not discuss the indications of external radiotherapy but specifies the volumes to be delineated if radiotherapy is considered.

The selection of target volumes for head and neck cancer radiation therapy, particularly prophylactic volumes that reflect infra-clinic spreads, is a complex process. It is based on the knowledge of the natural history of these tumors and must take into consideration the special challenges due to the diversity and complexity of head and neck anatomy. The dosimetric and ballistic precision provided by modern radiation techniques has required strong strategic deliberation to ensure the relevance and reproducibility of target volumes. Specifically, regarding cervical lymph node volumes, two issues emerged. What lymph node area to select depending on the location and the staging of the primary tumor? How to convey that choice in the process of treatment planning and delivery? This debate has been progressively enriched over time resulting in the publication of several international guidelines to standardize the terminology of head and neck lymph node areas and to lay solid science-based foundations to drive practices. This abundance of information makes these guidelines complex, but their accurate understanding is required for adequate usage. We provide an overview of the main published recommendations for the selection of lymph node target volumes when treating oral cavity and pharyngo-laryngeal squamous cell carcinoma with radiation therapy.

Despite progress in the management of head and neck squamous cell carcinoma (HNSCC), a significant proportion of patients previously irradiated for head-and-neck cancer will develop locoregional recurrence or a second primary. Because of the heterogeneity of this population with respect to disease-related factors (localization, volume, recurrence or second primary, time interval from previous irradiation…) and patient-related factors (comorbidities, sequelae of previous irradiation…), the optimal reirradiation treatment remains to be defined. Salvage therapy using reirradiation, despite some encouraging results, has historically been avoided because of concerns regarding toxicity. The results of more recent studies using contemporary treatment techniques and conformal delivery methods such as intensity modulated radiation therapy (IMRT) or stereotactic radiotherapy (SBRT) have been somewhat more promising. The aim of this review is to discuss the reirradiation of HNSCC in terms of patient selection and modern radiotherapy techniques.

Head and neck cancers comprise a variety of tumours depending on the sub-site, for which target volumes and the prescribed doses need to be individualized according to each patient's history and presentation. This article aims at describing the main factors involved in decision-making regarding dose and volume, as well as ongoing research. Contouring and treatment guidelines, use of altered fractionation, major prognostic factors, the role of Human papillomavirus and of functional imaging will be presented and discussed.

This article provides a proposal for the selection and delineation of clinical target volumes for the treatment with radiation of submandibular glands tumours. This article does not deal with external radiotherapy indications but specifies the volumes to be treated if radiotherapy is chosen. High-risk and low-risk peritumoral clinical target volumes are described based on the probability of local tumoral spread. High-risk and low-risk clinical target volumes are illustrated on CT-scan slices. A proposal for the selection of nodal clinical target volumeis also proposed.

Since decades, stereotactic radiotherapy has spread out worldwide. Published results are very numerous. To clarify obviousness among all the publications, this recommendation review was written. Voluntarily, authors limited analysis of international best evidence literature on malignant tumors of lung, liver, prostate, head and neck, and metastasis of bone and brain. These data could be used to advance standardization and quality improvement of treatments performed in the nationwide radiotherapy departments and can provide useful guidance for centers worldwide.

Salivary glands tumours are uncommon tumours showing a large diversity of histological types. This article presents a synthesis of patterns and paths of invasion of parotid glands tumours in order to propose an approach of the delineation of primary tumour clinical target volumes and of the selection of lymph nodes target volumes. This article does not discuss treatment indications but defines clinical target volumes to treat if radiotherapy is indicated. Postoperative situation being the most frequent, the delineation of primary tumour clinical target volume is based on an anatomical approach.

The objective of this study was to identify predictive factors of toxicity of docetaxel, platin, 5-fluorouracil (TPF) induction chemotherapy for locally advanced head and neck cancers.From July 2009 to March 2015, 57 patients treated consecutively with TPF were included retrospectively. There were 47 males (83%), the median age was 56 years [40-71 years]. Thirty-eight patients (67%) were treated for inoperable cancer (highly symptomatic and/or high tumor burden) and 19 (33%) were treated for laryngeal preservation. There were 47% stage IVa, 32% stage III and 21% stage IVb. At diagnosis, there were 53% stable weight, 28% grade 1 weight loss, 17% grade 2 weight loss and 2% grade 3 weight loss.Forty-seven percent of patients were in partial response after TPF, 28% in complete response, 7% stable, 2% progressing and 2% discordant response. The possibility of oral feeding without a feeding tube was predictive of a better response (P=0.02). Thirty-nine percent of patients increased weight during TPF, 35% were stable, 18% in grade 1 weight loss, 6% in grade 2 and 2% in grade 3. Six of the patients (10.5%) died during chemotherapy: four from febrile neutropenia, one from pneumopathy and one of unknown cause. Age 57years and older was associated with a higher risk of grade≥3 anemia and thrombocytopenia. There was a higher risk of grade≥3 infection for weight loss at diagnosis (P=0.04) and feeding tube (P=0.05). There was a higher risk of grade≥3 neutropenia for weight loss during TPF (P=0.03).Induction chemotherapy by TPF has an strong anti-tumor efficacy (75.5% objective response) but an important morbidity with 10% toxic deaths in our very symptomatic population with a very important tumor burden. Age and nutritional status are important factors to consider.

Stereotactic radiotherapy is a major issue in the management of brain metastases. Radionecrosis is a major concern, especially for large lesions. Optimizing dosimetric parameters is essential to allow optimal local control rate while minimizing potential toxicity. We report the case of a 30-mm brain metastases treated with stereotactic radiotherapy after initial whole brain radiotherapy, complicated with symptomatic radionecrosis. A dose of 24Gy in three fractions on the 80% isodose were delivered using a dynamic conformal arc technique (Novalis TX

Cerebral radiation-induced toxicities after radiotherapy (RT) of brain tumors are frequent. The protection of organs at risk (OAR) is crucial, especially for brain tumors, to preserve cognition in cancer survivors. Dose constraints of cerebral OAR used in conventional RT, radiosurgery (SRS) and stereotactic radiotherapy (SRT) are debated. In fact, they are based on historical cohorts or calculated with old mathematical models. Values of α/β ratio of cerebral OAR are also controversial leading to misestimate the equivalent dose in 2Gy fractions or the biological equivalent dose, especially during hypofractionated RT. Although recent progresses in medical imaging, the diagnosis of radionecrosis remains difficult. In this article, we propose a large review of dose constraints used for three major cerebral OAR: the brain stem, the hippocampus and the brain.

The GORTEC 2017-03-Stereo-postop study is a phase 2, multicentric, nationwide study, funded by the hospital clinical research program (PHRC). The sponsor is Centre Jean-Perrin in Clermont-Ferrand, in partnership with the GORTEC. The principal investigators are Dr J Biau and Dr M Lapeyre. The main objective is to study severe late toxicity of postoperative stereotactic radiotherapy (6×6Gy) for early stage oropharyngeal and oral cavity cancer with high risk margins. The secondary objectives include acute toxicity, efficacy, nutritional impact and quality of life. The population is adult patients, with pT1 or pT2 squamous cell carcinoma of the oropharynx or oral cavity (except lips), without indication of neck irradiation or concomitant chemotherapy, with at risk margin (R1, less than 5mm or uncertain). Ninety patients will be included over a 2-year period; this was calculated to limit the rate of 2-year severe toxicity at 5 to 15%, with a 2-year local control of at least 80 to 90%. If this study is considered as positive, stereotactic radiotherapy (6×6Gy) could become the third therapeutic option, with brachytherapy and normofractionated intensity-modulated radiotherapy (IMRT), for postoperative irradiation of oropharyngeal and oral cavity cancer with high risk margins.

Adrenal glands are a common site for metastatic spread since they represent the fourth metastatic site of solid tumors. Interest in local ablative treatments of oligometastases is growing since literature suggests better progression-free survival, quality of life and potentially overall survival in selected patients. Surgery remains the first treatment of adrenal oligometastases because results are good, with a long enough follow-up. However, stereotactic radiotherapy appears to be comparable to surgery and could be proposed to elderly, unfit, inoperable patients, or even to patients whose systemic treatment should not be suspended for too long. This article aims to present a review of published studies to date on stereotactic radiotherapy of adrenal metastases and to propose a treatment protocol.

Gliomas are the most frequent primary brain tumours. Treating these tumours is difficult because of the proximity of organs at risk, infiltrating nature, and radioresistance. Clinical prognostic factors such as age, Karnofsky performance status, tumour location, and treatments such as surgery, radiation therapy, and chemotherapy have long been recognized in the management of patients with gliomas. Molecular biomarkers are increasingly evolving as additional factors that facilitate diagnosis and therapeutic decision-making. These practice guidelines aim at helping in choosing the best treatment, in particular radiation therapy.

Intensity modulated radiation therapy (IMRT) and brachytherapy are standard techniques for the irradiation of oral cavity cancers. These techniques are detailed in terms of indication, preparation, delineation and selection of the volumes, dosimetry and patient positioning control.

Intensity modulated radiotherapy for prostate cancer involves daily monitoring of the positioning of the prostate, possible with cone beam CT (CBCT). It allows increased accuracy compared to readjustments but induces an increase in the time dedicated to these medical checks. The aim of the study was to evaluate the possibility of delegation of this task to the radiation therapists by comparing their readjustments to the doctors.Five consecutive patients treated with radiation for prostate cancer (76Gy) were analysed. All had a daily CBCT for position control. The movements of the prostate relative to the bony part, the positional variations of the prostate measured by the radiation therapists and the doctors and medical time required to analyse imagery (filling of the rectum and bladder and perform a recalibration) were measured.One hundred seventy-six CBCT were analysed or 980 steps in the three axes. The movements of the prostate relative to bony part were respectively at least 5mm in 19%, 7% and 3% in the anterior-posterior, upper-lower and right-left axes. Changes readjustments between radiation therapists and doctors were in 95% of cases at the most 4mm in the anterior-posterior and upper-lower axis, and 3mm in the left-right axis. The time for medical use of the CBCT averaged 8min 40 [4 to 22min].The daily readjustment on the prostate using CBCT may be delegated to radiation therapists with acceptable concordance of less than 4mm for 95% of measurements. An initial and ongoing training will ensure treatment safety.

Pathological fractures of the humerus are associated with pain, morbidity, loss of function and a diminished quality of life. We report our experience of stabilising these fractures using polymethylmethacrylate and non-locking plates. We undertook a retrospective review over 20 years of patients treated at a tertiary musculoskeletal oncology centre. Those who had undergone surgery for an impending or completed pathological humeral fracture with a diagnosis of metastatic disease or myeloma were identified from our database. There were 63 patients (43 men, 20 women) in the series with a mean age of 63 years (39 to 87). All had undergone intralesional curettage of the tumour followed by fixation with intramedullary polymethylmethacrylate and plating. Complications occurred in 14 patients (22.2%) and seven (11.1%) required re-operation. At the latest follow-up, 47 patients (74.6%) were deceased and 16 (25.4%) were living with a mean follow-up of 75 months (1 to 184). A total of 54 (86%) patients had no or mild pain and 50 (80%) required no or minimal assistance with activities of daily living. Of the 16 living patients none had pain and all could perform activities of daily living without assistance. Intralesional resection of the tumour, filling of the cavity with cement, and plate stabilisation of the pathological fracture gives immediate rigidity and allows an early return of function without the need for bony union. The patient’s local disease burden is reduced, which may alleviate tumour-related pain and slow the progression of the disease. The cemented-plate technique provides a reliable option for the treatment of pathological fractures of the humerus.

In medical research, commonly, one is interested in the time to the occurrence of a particular event, such as the revision of an implant, and the analysis of these data is referred to as survival analysis. However, for some patients, the event is not observed and their observations are censored. These censored observations are particular to survival data and require specific methods for estimation. The Kaplan and Meier method is a popular method to estimate the probability of being free of the event over time and it is now widely applied in orthopaedics such as to report implant survival. However, one of the assumptions underlying the Kaplan-Meier estimator implies that patients whose observations are censored have the same risk of occurrence of the event than patients remaining in the study. However, because the revision of an implant cannot occur after a patient dies, and that dead patients have their observations censored in the Kaplan-Meier method, another setting must be considered. In the sequel we will demonstrate the inadequacy of the Kaplan-Meier method to estimate implant survival and detail the cumulative incidence estimator.

The cumulative summation (CUSUM) test is increasingly being used in medicine to monitor a wide variety of processes such as cardiac surgery or disease outbreaks. The CUSUM sequentially tests the null hypothesis that the process is in control, i.e. its mean is equal to a given target. Thus, it detects when the process changes to an out of control state. Conversely, monitoring the learning curve requires detecting the time when the process reaches an in control state. In this work we develop an alternative to the CUSUM, the learning curve CUSUM (LC-CUSUM), that serves to detect when a process deviates from an out of control state to an in control state. The test is based on a two one-sided tests procedure where the null hypothesis is that the process is out of control. This can be written as H(0): |mu-mu(0)|> or =delta tested against H(1): |mu-mu(0)|< delta. The null hypothesis is thus the union of two one-sided hypotheses and is rejected when both are rejected. A CUSUM test statistic is then constructed for each hypothesis in a traditional way. The properties of the test are investigated through numerical simulations, and are illustrated on the learning curve of an endoscopist performing endoscopic retrograde cholangiopancreatographies for biliary tract disorders.

This study aimed to analyse the positioning protocols with the ExacTracA survey, including three questions about the prescription of irradiation and twenty-one questions about how the ExacTracAll centres checked the positioning before each treatment's bow, with residual mismatch tolerances of 0.5 to 0.7mm for the translations and 0.5 to 1° for the rotations. All centres except one also realised orthogonal planar images of classic incidences to help operators ensure proper isocentre positioning. Prescribed doses were 20Gy in one fraction, 30Gy and 33Gy in three fractions or 34Gy in four fractions, mainly depending on the size of the lesion. Finally, a physician validated the images at the treatment station before starting the irradiation.The practices of the different centres concerning the positioning protocols were rather homogeneous, in agreement with the literature data on ExacTrac

Head and neck cancers have been widely studied concerning their sensitivity to radiation therapy. Several parameters affect tumour response to radiation therapy. Some parameters are linked to the tumour. Large or invasive tumours, localization, such as oral cavity or adenopathy, are factors of radioresistance. Others parameters are linked to the patients themselves. Tobacco intoxication during radiotherapy and a low hemoglobin level contribute to radioresistance. More recently, a positive human papilloma virus (HPV) status has been reported to positively affect radiosensitivity. Finally, other parameters are related to tumour biology. Hypoxia, intrinsic radiosensitivity of tumour cells, tumour differentiation and repopulation (provided by Ki-67 index or EGFR level) are components of radiosensitivity. Currently, concurrent chemoradiotherapy is one of the gold standard treatments to overcome clinical outcome of locally advanced head and neck cancer. This combination increases locoregional control and survival. Taxane-based induction chemotherapy can also be an alternative. Another validated approach is the association of radiotherapy with cetuximab (EGFR targeting) but only one randomized study has been published. Fractionation modifications, especially hyperfractionation, have given positive results on both tumour control and survival. Strategies targeting hypoxia improve locoregional control but have less clinical impact.

The aim of this article is to present the determination and delineation of nodal target volumes for head and neck cancers treated with intensity-modulated radiotherapy. The delineation on computerized tomography scanner (CT scan) requires a precise methodology. Different elements are necessary: clinical examination, diagram of the initially involved lymph nodes, surgical and pathological reports and medical imagings (CT scan, magnetic resonance imaging and fluorodeoxyglucose positron emission tomography). The different clinical target volumes are approached and the concept of selectivity of neck nodal targets is specified according to current literature.

Numerous studies have shown that intensity-modulated radiation therapy is the standard technique for the radiation treatment of head and neck cancers. Intensity-modulated radiation therapy reduces side effects (xerostomia, dysphagia, fibrosis, etc.) and improves the results for cancer localizations with highly complex shapes such as the cavum or nasal cavity. Intensity-modulated radiation therapy is also a costly technique that necessitates a numerous staff, highly trained, with regular practice. If this technique cannot be available (understaffing, overwork, etc.) the choice between entrusting the patient to a colleague and treating the patient with a less sophisticated technique such as 3-dimensional conformal radiation therapy depends on different objective and ethical criteria.

The aims of this study were to determine if the learning curve cumulative summation test (LC-CUSUM) can differentiate proficiency in placing intravenous catheters by novice learners, and identify the cause of failure when it occurred. In a prospective, observational study design 6 undergraduate students with no previous experience of placing intravenous catheters received standardized training by a board certified veterinary anesthesiologist in intravenous catheter placement technique. Immediately following training, each student attempted 60 intravenous catheterizations in a dog mannequin thoracic limb model. Results were scored as a success or failure based upon completion of four specific criteria, and where catheter placement failure occurred, the cause was recorded according to pre-defined criteria. Initial acceptable and unacceptable failure rates were set by the study team and the LC-CUSUM was used to generate a learning curve for each student. Using 10% and 25% acceptable and unacceptable failure rates, 3 out of 6 students attained proficiency, requiring between 26 to 48 attempts. Applying 25% and 50% acceptable and unacceptable failure rates, 5 of 6 students obtained proficiency, requiring between 18 and 55 attempts. Wide inter-individual variability was observed and the majority of failed catheterisation attempts were limited to two of the four pre-defined criteria. These data indicate that the LC-CUSUM can be used to generate individual learning curves, inter-individual variability in catheter placement ability is wide, and that specific steps in catheter placement are responsible for the majority of failures. These findings may have profound implications for how we teach and assess technical skills.

The various image-guided radiotherapy techniques raise the question of how to achieve the control of patient positioning before irradiation session and sharing of tasks between radiation oncologists and radiotherapy technicians. We have put in place procedures and operating methods to make a partial delegation of tasks to radiotherapy technicians and secure the process in three situations: control by orthogonal kV imaging (kV-kV) of bony landmarks, control by kV-kV imaging of intraprostatic fiducial goldmarkers and control by cone beam CT (CBCT) imaging for prostate cancer. Significant medical overtime is required to control these three IGRT techniques. Because of their competence in imaging, these daily controls can be delegated to radiotherapy technicians. However, to secure the process, initial training and regular evaluation are essential. The analysis of the comparison of the use of kV/kV on bone structures allowed us to achieve a partial delegation of control to radiotherapy technicians. Controlling the positioning of the prostate through the use and automatic registration of fiducial goldmarkers allows better tracking of the prostate and can be easily delegated to radiotherapy technicians. The analysis of the use of daily cone beam CT for patients treated with intensity modulated irradiation is underway, and a comparison of practices between radiotherapy technicians and radiation oncologists is ongoing to know if a partial delegation of this control is possible.

The aim of this article is to present the determination and the delineation of target volumes for oral cavity and oropharyngeal carcinomas treated with intensity-modulated irradiation. The delineation on the computerized tomography scanner (CT scan) requires a precise method because of the complexity of the head-and-neck anatomy. Different elements are necessary: clinical examination, diagram of the initial tumor, surgical and pathological reports and medical imaging (CT scan, magnetic resonance imaging and fluorodeoxyglucose positron emission tomography). The clinical target volumes, the planning target volumes, the organs at risk and the planning organs at risk volumes are discussed. The concept of selectivity of the potential subclinical disease near the primary tumour and the selection of neck nodal targets are specified according to the literature.

Daily set up of patients with prostate cancer using orthogonal kV/kV imaging and weekly set up control require 1h to 1h30 of off line revision by a radio-oncologist per day and per accelerator. The aim of this study was to evaluate the possibility to delegate this control to radiation therapists.The files of 33 patients (including 13 with prostate cancer) treated from November 2010 to February 2011 on a Varian™ Clinac IX accelerator with an OBI™ system were evaluated. Radiation therapists made the daily kV/kV imaging. Radiation therapists made the online control by kV/kV for patient repositioning and radio-oncologists made the offline reviews; the results were compared and analysed (seven radiation therapists and seven radio-oncologists). For an isocentre displacement of 5mm, the radiation therapist had to call the radio-oncologist to make a medical decision (treatment or patient displacement). The difference of measures and the concordance of decisions between radiation therapists and radio-oncologists were calculated.Five hundred and fifty-six measures were made for 33 treatments, including 226 measures for prostate cancer treatment. The difference of measures between radiation therapists and radio-oncologists was 3mm or less in 93.7% for all treatments and 96.2% for prostate cancer treatment. The concordance of decision between radiation therapists and radio-oncologists for measures up to 4mm was 97% (CI95±2%) vs. 57% (CI95±10%) for measures equal to or higher than 5mm (P0.0001).Radiation therapists are able to do daily set up using kV/kV on the bony structures of patients with prostate cancer, with a risk of disagreement higher than 3mm less than 4%. The weekly set up controls (different primaries) can be delegated to the radiation therapists, subject to an accurate procedure using a medical alert for a given threshold. Training and competence certification are required to secure the process.

The standard of care for isolated extremity osteosarcoma in adolescents and young adults has changed very little in the last twenty years1. Chemotherapeutic regimens including doxorubicin, cisplatin, and high-dose methotrexate have predominated, and the timing of treatments has also changed very little. Most patients receive some portion of their chemotherapy prior to surgical local control (termed neoadjuvant chemotherapy) and then additional adjuvant chemotherapy following surgical resection. As so much of this care standard has been subjected to repeated evaluation in randomized controlled clinical trials1, it may be assumed that the timing of treatments is similarly evidence-based. It is not. The timing of treatments is instead rational, based on the following four considerations that led to its development and incorporation into common practice. First, early in the days of limb salvage surgery, neoadjuvant chemotherapy was undertaken to delay definitive surgery to permit the fabrication of the custom endoprosthetic implants then used for limb salvage reconstructions. Second, neoadjuvant chemotherapy permitted measurement of the treatment effect on the primary tumor2 in the form of preoperative chemotherapy-induced tumor necrosis, thereby providing a surrogate measure of chemotherapeutic response and eradication of clinically undetectable microscopic metastatic disease. Third, treating physicians thought that initiating systemic treatments quickly put priorities in proper philosophical order, with an upfront attack on the deadly presumed systemic disease, rather than an initial focus on the primary tumor and local control. Fourth, surgeons preferred performing close-margin resections around tumors that had been largely treated already. Often-touted potentially advantageous treatment effects of neoadjuvant chemotherapy included tumor size reduction, clearing of peritumoral edema on magnetic resonance imaging (MRI) scans, development of a rind or pseudocapsule, and increased palpable firmness of the tumor. The first rationale has largely disappeared now that modular implants and large regional and national allograft tissue repositories are available. The second rationale remains, but provides only prognostic information rather than treatment guidance, as changing protocols following a poor histological response (limited tumor necrosis) to preoperative chemotherapy does not improve prognosis3. In a Pediatric Oncology Group study beginning in the late 1980s, investigators attempted to provide evidence for the third rationale, but the study was closed after years of insufficient patient accrual4. The reason suspected for the poor enrollment was that many surgeons already believed too firmly in the fourth rationale to enroll their patients for possible randomization to the immediate-surgery arm when limb salvage was planned. Although they failed to reach significance, the published results trended toward improved survival in the immediate-surgery group4. This study’s underpowered results did not slow the acceptance of neoadjuvant chemotherapy as the standard of care for patients with osteosarcoma. Thus, even the lack of data for the third rationale is the result of the yet unstudied fourth rationale, that neoadjuvant chemotherapy makes local control surgery easier or safer. While a number of modalities have been tested with regard to their value in noninvasively measuring the treatment effect of neoadjuvant chemotherapy on the primary tumor prior to local control surgery, no modality has been sufficiently successful at predicting the treatment effect to be widely adopted by sarcoma treatment centers5-14. While evaluation of changes between pre-chemotherapy and post-chemotherapy MRIs has not proven to accurately predict histologically confirmed treatment effects, these MRIs are still almost universally used by surgeons to plan local control resections15. Furthermore, MRI is the most accurate noninvasive means of staging the local bone and soft-tissue extent of sarcomas, including compartmental spread, neurovascular involvement, and intra-articular spread16-22. We investigated the effect of neoadjuvant chemotherapy on MRI-based surgical planning for osteosarcoma. Even a tumor that has responded well to preoperative chemotherapy in terms of histological necrosis may have progressed with regard to surgically critical anatomy. This study was undertaken to evaluate the surgically important anatomic effects of neoadjuvant chemotherapy. Because the practice standard of neoadjuvant chemotherapy was deeply entrenched and we had no reason to believe that it was erroneous, we thought that it was both impractical and unethical to randomize patients to immediate surgery or neoadjuvant chemotherapy followed by surgery. Instead we chose to evaluate the practice in a pilot study using available data from existent MRIs. In order to measure surgically important anatomic changes on these MRIs, we developed a surgical planning questionnaire focused on the distal part of the femur, assessed its reliability across different surgeons, and tested it against a separate validation in the form of radiologists assessing the same MRIs with their own anatomic details questionnaire. With this tool, we could then safely ask our question: does neoadjuvant chemotherapy change the surgical resections planned by surgeons for distal femoral osteosarcomas?

Quality control is receiving increasing attention from surgeons as a key to meeting the needs of patients and the requirements of health care authorities. The objective of the study was to evaluate a continuous monitoring program for surgical performance in anterior cruciate ligament reconstruction. We measured the differential anterior knee laxity immediately after anterior cruciate ligament reconstruction by two experienced surgeons. Surgical technique including the choice of ancillary devices and implant material was at the surgeon’s discretion. The target was an immediate postoperative differential knee laxity at 20° of knee flexion of −1.5 mm. The cumulative summation test (CUSUM) was used to detect inadequate performance. Seventy-nine consecutive patients were included in the study. Median postoperative differential knee laxity at 20° flexion was −2 mm (interquartile range −4 to 0 mm; SD = 2.3). The CUSUM test at 20° knee flexion emitted an alarm at the 12th procedure, indicating that performance was inadequate with a tendency for laxity to be above the target of −1.5 mm. Two alarms were emitted after the 28th procedure, indicating that laxity tended to be below the target. Monitoring of immediate postoperative differential anterior knee laxity in anterior cruciate ligament reconstruction is feasible and can provide useful information on actual surgeon performance. Clinical relevance: continuous monitoring of the quality of anterior cruciate ligament reconstruction may help surgeons to detect deviations from optimal performance when new surgical techniques and innovative fixation devices are introduced.

Our objective was to determine the reproducibility and validity of urine retention volumes measured by 3D ultrasonography (3D-US) 2 h postpartum. This was a longitudinal prospective study of 100 women who delivered vaginally. Each woman underwent five successive urine retention measurements with the Bladder Scan 2 h after vaginal delivery, followed by transurethral catheterization to determine the real volume. The reproducibility of only the last four scan values was analyzed with an intraclass correlation coefficient, and that of determinations 4 and 5 with a Bland-Altman plot. The validity of the device was similarly evaluated using the mean four-scan and real values. Pearson's correlation coefficient was calculated and a least-trimmed squares robust linear-regression model was used. All tests were two-sided with a 5% alpha risk. Results showed that 3D-US measurements were highly reproducible, with an intraclass correlation coefficient of 0.974 (95% CI:0.964-0.981). 3D-US also accurately estimated the real urine volume (intraclass correlation coefficient 0.924; 95% CI:0.888-0.949), but tended to underestimate by about 6.8%. The between-technique Pearson correlation coefficient was 0.94 (P0.0001) and the regression analysis gave an R2 of 0.914. Urine retention volumes exceeded 500 ml in 55 women, and 11 in 7. We concluded that 3D-US was reliably able to measure postpartum urine retention volume.

BackgroundThe best means of ensuring knee stability after anterior cruciate ligament (ACL) reconstruction remains a core debate in sports medicine.HypothesisThere is no difference between ACL reconstruction with patellar tendon or hamstring tendon autografts with regard to postoperative knee laxity and instability.Study DesignMeta-analysis of individual patient data.MethodsPooled analysis of individual patient data from 6 published randomized clinical trials included 423 patients with symptomatic unilateral anterior cruciate ligament injury randomly assigned to reconstruction with patellar tendon or hamstring tendon autograft. Knee instability, defined as a positive pivot-shift test result, was the primary outcome, and knee laxity, defined as a positive Lachman test result, was the secondary outcome. Odds ratios were computed before and after adjustment for potential confounders and trial effect. Regression analyses were performed to look for effects of covariates on outcomes, and mixed-effects models were used to account for a trial effect. Sensitivity analyses were conducted to explore the effects of missing data and excluding each trial.ResultsAnterior cruciate ligament reconstruction with patellar tendon autograft was significantly associated with a decreased risk of a positive pivot-shift test result (adjusted odds ratio, 0.46; 95% confidence interval, 0.24–0.86; P = .016). The risk of having a positive Lachman test result was not significantly different between the 2 groups. The estimated treatment effect was not substantially changed by differences in handling missing data or exclusion of any of the trials. A positive pivot-shift test result was more common in female ( P = .003) and younger patients ( P = .017).ConclusionPostoperative knee instability was less common after ACL reconstruction with patellar tendon autograft than with hamstring tendon autograft.