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We present the results of two retrospective studies, one regarding reirradiation of spinal tumours and the second, concerning lung tumours. In the first case, primary or secondary tumours were located in or in contact with the vertebrae and spinal cord. The first irradiation has given a full dose to the spinal cord. In the second case, primary or secondary lung tumours have already been treated by irradiation alone or by radiochemotherapy. No grade 3 or 4 early toxicity has been found. Preliminary clinical results are encouraging. The use of CyberKnife represents a major therapeutic advance in the management of irradiated spinal or lung lesions. The possibility of sparing organs at risk and increasing the dose in the tumour target volume are the main advantages., (Copyright © 2010 Société française de radiothérapie oncologique (SFRO). Published by Elsevier SAS. All rights reserved.)

Xerostomia is one of the most a common complication of radiotherapy for head and neck cancers, affecting quality of life. Parotid glands produce approximately 60% of saliva and submandibular glands 20% of saliva while the rest is secreted by sublingual and accessory salivary glands. Methods of measuring the salivary output are collection of unstimulated or stimulated saliva or 99mTc-pertechnate scintigraphy. Several studies demonstrated that late salivary dysfunction after radiotherapy has been correlated to the mean parotid gland dose, with recovery occurring with time. Severe xerostomia could be avoided if at one parotid gland is spared to a mean dose of less than approximately 25-30 Gy. Clinical benefit of submandibular gland sparing is more controversial. A mean dose less than 39 Gy could preserve submandibular gland function. This paper aims to review main studies evaluating tolerance dose of salivary glands., (Copyright (c) 2010 Société française de radiothérapie oncologique (SFRO). Published by Elsevier SAS. All rights reserved.)

The aims of this retrospective study were to evaluate prosthetic voice restoration by tracheoesophageal puncture (TEP) in laryngectomized patients and to identify clinical factors correlated with functional outcomes. Between 2000 and 2008, 103 patients who underwent total laryngectomy or pharyngolaryngectomy (TPL) were included in our study. Functional outcomes were recorded 6 months postoperatively, and results were scored from 0 to 2 for oral diet and speech intelligibility. Lifetime of voice prosthesis and early and late complications were recorded. The impact of several clinical factors on functional outcomes, prosthetic valve lifetime and complications was assessed in univariate analysis. A total of 87 patients (84%) underwent TEP and speech valve placement (79 primary and 8 secondary punctures). Hypopharyngeal tumors (P = 0.005), circular TPL (P = 0.003) and use of a pectoralis major myocutaneous flap (P = 0.0003) were significantly associated with secondary TEP. Successful voice rehabilitation was obtained by 77 of 82 evaluable patients (82%). A high level of comorbidity (ASA score > or = 3; P = 0.003) was correlated to speech rehabilitation failure. The median device lifetimes were 7.6 and 3.7 months for Provox I and II speech valves, respectively. Minor leakage around the valve occurred in 26% of the patients. Late complications occurred in 14 patients (16%) including: severe enlargement of the fistula (n = 3), prosthesis displacement (n = 7) and granulation tissue-formation (n = 4). In conclusion the use of voice prosthesis showed a high success rate of vocal rehabilitation with an acceptable complication rate.

Purpose: Stereotactic radiotherapy using the CyberKnife has become a key treatment in the multidisciplinary management of secondary tumours, as well as primary benign or malignant tumours located within or adjacent to vertebral bodies and the spinal cord. The aim of this treatment is to improve local control and clinical response, including previously irradiated cases., Patients and Methods: In this study, we present the first patients treated with CyberKnife between December 2006 and December 2007 for spinal or paraspinal tumours. The primary aim was to assess the feasibility and tolerance of stereotactic radiotherapy using the CyberKnife. Secondary aims were to establish the short-term local control, to calculate the local progression-free survival and overall survival. Clinical examination and imaging procedures were performed every three months. Response was assessed according to RECIST criteria., Results: During that period, 16 patients were treated with CyberKnife. Thirteen patients had been pre-treated, three of whom had received spinal cord doses considered to be maximal. Three patients did not receive previous irradiation. The median age was 59 (36-74). The most frequent symptoms were pain (n = 8) and motor weakness (n = 4). The median dose was 30 Gy (16-50). The median number of fractions was 3 (1-5). No patient developed acute myelitis. Three patients developed acute reaction. Overall survival at 18 months was 72.4%, with a mean survival of 18.2 months (95% CI: 15.4-20.9). Local progression-free survival at 18 months was 58.4%, with a mean value of 16.9 months (95% CI: 13.6-20.2)., Conclusion: The use of stereotactic radiotherapy with CyberKnife represents a major progress in the management of paraspinal tumours. The main advantages are better sparing of the spinal cord and the possibility of increasing the dose to the tumour target volume., (2009 Société française de radiothérapie oncologique (SFRO). Published by Elsevier SAS. All rights reserved.)

Objectives: We describe a case of an unusual remnant tooth located in the paranasal sinus in a head and neck cancer patient., Case Report: A 72-year patient with a history of T3N2aM0 oropharyngeal cancer treated with chemoradiation came for systematic post-therapeutic multidetector-CT reformation (MDCT) examination. MDCT scan multi planar reformation revealed a well-limited high-density mass in his maxillary sinus, which proved to be a remnant molar tooth. Physical examination and CT imaging were performed at 26 months. Local malignancy, fungal ball and persistent oroantral fistula were ruled out., Conclusion: The physio-pathogenesis of oroantral fistula (OAF) and causes of intra sinusal tooth as well as therapy are discussed in this article.

Purpose: We report the experience of two French cancer centers in the treatment of oral cavity squamous cell carcinoma (SCC) in patients aged 80 years., Materials and Methods: Two hundred and sixty patients aged 80 years with a primary oral cavity SCC were included in this retrospective analysis., Results: Sex ratio was near to 1. Tobacco or alcohol intoxication was the main risk factor for 66% of men and 16% of women and leukoplakia, lichen planus, or oral traumatism for 55% of women and 11% of men (p<0.0001). Two hundred patients received a loco-regional (LR) treatment with a curative intent (surgery and/or radiotherapy), 29 with a palliative intent and 31 did not receive a LR treatment. Curative treatments were initially planned to be adapted to age in 118 patients (59%). The median disease-specific survival (DSS) was 29 months. In multivariate analysis, the independent prognostic factors for DSS were stage (HR=0.42 [0.24-0.72]), age (HR=0.43 [0.24-0.75]) and performance status (HR=0.50 [0.27-0.95]). The median overall survival (OS) was 14 months. In multivariate analysis, the independent prognostic factors for OS were age (HR=0.52 [0.35-0.79]), stage (HR=0.56 [0.38-0.84]), tumor differentiation (HR=0.60 [0.33-0.93]) and performance status (HR=0.6 [0.37-0.97]). In patients treated with a curative intent, treatment adapted to age was not associated with a decreased overall survival or disease-specific survival as compared with the standard treatment. However, prophylactic lymph node treatment in stages I-II tumors decreased the rate of nodal recurrence from 38% to 6% (p=0.01)., Conclusion: This study emphasizes the need for prospective evaluation of standard and adapted schedules in elderly patients with oral cavity cancer.

Objective: To evaluate quality of life (QOL) after radial forearm free flap (RFFF) reconstruction of the oral cavity and oropharynx in head and neck cancer patients., Design: Prospective study., Setting: Academic, tertiary referral centre., Methods: Between January 2004 and May 2005, 47 patients underwent immediate RFFF reconstruction of the oral cavity and oropharynx following ablative surgery for a previously untreated head and neck cancer and were initially included in this study. The European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire and the EORTC Head and Neck Cancer Quality of Life Questionnaire were completed before surgery and at 6 and 12 months thereafter., Main Outcome Measures: QOL scores obtained at the three assessment dates. Predictive factors of QOL scores at 6 months researched among the following: age, gender, comorbidity, radiotherapy, tumour stage, and tumour site., Results: Global QOL remained stable over time. Social and role functioning scores deteriorated significantly after treatment. Social eating and speech difficulties, trismus, and salivary problems increased significantly in the postoperative period and were among the main complaints of our patients., Conclusions: Despite some functional impairment, global QOL was preserved after RFFF reconstruction following extensive ablative surgery in patients with oral and oropharyngeal cancer.

Conclusions: Radical ablative surgery and radial forearm free flap (RFFF) reconstruction provide promising oncologic and functional results in patients with oral or oropharyngeal cancer., Objectives: To assess the postoperative outcomes and the oncologic and functional results, with their main predictive factors, after radical ablative surgery and RFFF reconstruction for patients with oral or oropharyngeal cancer., Patients and Methods: Between 2000 and 2006, we prospectively analyzed the postoperative, oncologic and functional outcomes of all previously untreated patients who underwent this type of surgery., Results: A total of 132 patients were enrolled in this study. There were three RFFF failures. The rate of surgical complications was 20%. The 5-year locoregional control and overall survival rates were 68% and 52%, respectively. Advanced age, high comorbidity index, elevated overall stage and tumoral involvement of the inner part of the cheek were correlated with a lower overall survival rate. A good functional result was obtained for oral diet, speech, mouth opening and aesthetic outcome in 87%, 80%, 86% and 88% of the patients, respectively. High comorbidity index, large flap surface, radiotherapy and tumoral involvement of the mobile tongue were significant predictors of poorer functional or aesthetic outcomes.

Neoadjuvant chemoradiotherapy is considered at the present time as the standard treatment of most T3-4 rectal cancer. In France a combination of radiotherapy (45 Gy/5 weeks) with concurrent capecitabine (1,600 mg/m2) is the most popular protocol. Randomized trials try to optimize this approach using new cytotoxic drugs and/or radiation dose-escalation. The introduction of biotargeted therapies (anti-EGFR or antiangiogenic) is an attractive field especially selecting the treatment according to K-ras mutation. For T2 and 'early T3' present studies are using neoadjuvant chemoradiation followed by transanal local excision in case of good tumor response. In frail elderly patients, a new trend is to use mainly exclusive irradiation to control the tumor and avoid the excessive toxicity of open surgery in this group of patients. As rectal cancer is presenting many different clinical situations, an individualised treatment appears justified.

Purpose: The mathematical relationship between the dose to the parotid glands and salivary gland production needs to be elucidated. This study, which included data from patients included in a French prospective study assessing the benefit of intensity-modulated radiotherapy (RT), sought to elaborate a convenient and original model of salivary recovery., Methods and Materials: Between January 2001 and December 2004, 44 patients were included (35 with oropharyngeal and 9 with nasopharyngeal cancer). Of the 44 patients, 24 were treated with intensity-modulated RT, 17 with three-dimensional conformal RT, and 2 with two-dimensional RT. Stimulated salivary production was collected for 40 Gy., Conclusion: The results of this study show that the recommendation of a dose constraint for intensity-modulated RT planning should be established at the volume of the contralateral parotid gland receiving >40 Gy rather than the mean dose. For complete salivary production recovery after 24 months, the volume of the contralateral parotid gland receiving >40 Gy should be <33%. Our results permitted us to establish two convenient tools to predict the saliva production recovery function according to the dose received by the contralateral parotid gland.

Background: Scarce data exist concerning the outcome of very elderly patients with head and neck squamous cell carcinoma (HNSCC)., Methods: The clinical files of 316 patients aged > or = 80 years with HNSCC who were included in the authors' hospital database between 1987 and 2006 were reviewed retrospectively., Results: Approximately 88% of patients received locoregional treatment, 31% of patients underwent surgery, and 57% of patients received definitive radiotherapy. The median disease-specific survival (DSS) was 21.3 months, and a plateau was observed after 5 years. The median overall survival (OS) was 13.0 months. Both the median DSS and the median OS were longer for patients with stage I/II HNSCC than for patients with stage III/IV HNSCC (median DSS, not reached vs 11.4 months; P < .001; median OS, 41.9 months vs 7.9 months; P < .001). On multivariate analysis, stage I/II disease, treatment with curative intent, and evidence of locoregional control were independent predictors of improved survival., Conclusions: The outcome of patients with stage I/II HNSCC aged > or = 80 years was similar to that of younger patients, and the current results indicated that age should not be used to deny them optimal treatment. Elderly patients with stage III/IV HNSCC had poor survival. Geriatric tools should be used to identify elderly patients who are eligible for optimal locoregional treatment., ((c) 2008 American Cancer Society)

Purpose: High-dose robotic stereotactic irradiation can be achieved with high precision using the CyberknifeM system equipped with the Synchrony respiratory tracking device. Cyberknife irradiation can overcome some limitations of conventional radiotherapy including errors due to breathing motion and patient setup. High dose levels are of interest for tumours that have shown a dose-response relationship including lung tumours. We reviewed the treatments and outcomes for the first French patients with lung tumours treated at the Cyberknife centre of Nice., Patients and Methods: Thirty four patients were treated between November 2006 and November 2007 at the Cyberknife centre of Nice, Centre Lacassagne, France. Thirty had untreated primary lung cancer, 4 had colorectal metastasis to the lung. We evaluated the feasibility and reliability of fiducial placement, toxicity and early outcomes. Objective tumour response was assessed on thoracic CT scan every three months., Results: There was no grade 3-4 toxicity. Toxicity (11%) mainly consisted of grade 1-2 asthenia. Crude overall tumour response rate was 96% for all assessable patients and 91% at 3 and 6 months, respectively. The use of one fiducial ensured minimal toxicity (no grade III pneumothorax) while allowing reliable tumour tracking as shown by the low infield failure rate (no geographic miss). Diagnostic procedure was performed during fiducial placement when required., Conclusion: Early toxicity and tumour control rates from this population suggest that the use of a unique fiducial for a Cyberknife treatment was safe and effective for the treatment of selected primary and secondary lung tumours. This strategy is corroborated by similar control rates in the literature. Longer follow-up are awaited.

Purpose: To report the results of using contact X-ray (CXR), which has been used in the Centre-Lacassagne since 2002 for rectal cancer., Methods and Materials: A total of 44 patients were treated between 2002 and 2006 using four distinct clinical approaches. Patients with Stage T1N0 tumors were treated with transanal local excision (TLE) and adjuvant CXR (45 Gy in three fractions) (n = 7). The 11 inoperable (or who had refused surgery) patients with Stage T2-T3 disease were treated with CXR plus external beam radiotherapy (EBRT). Those with Stage T3N0-N2 tumors were treated with preoperative CXR plus EBRT (with or without concurrent chemotherapy) followed by surgery (n = 21). Finally, the patients with Stage T2 disease were treated with CXR plus EBRT followed by TLE (n = 5)., Results: The median follow-up was 25 months. In the 7 patients who underwent TLE first, no local failure was observed, and their anorectal function was good. Of the 11 inoperable patients who underwent CXR plus EBRT alone, 10 achieved local control. In the third group (preoperative CXR plus EBRT), anterior resection was performed in 16 of 21 patients. Complete sterilization of the operative specimen was seen in 4 cases (19%). No local recurrence occurred. Finally, of the 5 patients treated with CXR plus EBRT followed by TLE, a complete or near complete clinical response was observed in all. TLE with a R0 resection margin was performed in all cases. The rectum was preserved with good function in all 5 patients., Conclusion: These early results have confirmed that CXR combined with surgery (or alone with EBRT) can play a major role in the conservative and curative treatment of rectal cancer.

Aim: To compare technical feasibility and complications of radiologically arm port device implantation using arm venography exclusively (API-Group B) with chest port placement using cephalic vein cutdown (CVC-Group A), in advanced consecutive head and neck cancer patients (HNP)., Methods: Port device placement was attempted in 225 consecutive HNP. Decision for inclusion in Group A or B was made first by the availability of the surgeon/radiologist to perform the procedure, second by contraindications of each technique. Patient transfer from one group to the other was recorded as well as technical feasibility, complications and device specific duration in this retrospective study., Results: Technical success was statistically higher in Arm Port Group (99.1%) compared to Chest Port Group (75.2%). Device specific duration rate of the whole population was 53% (95%CI) [0.47-0.60] at 6 months, 44.1% (95%CI) [24.4-37.8] at 12 months and 8% (95%CI) [4.4-14.5] at 24 months. Median follow-up was 5.55 months (range: 0.032-9.6] in Group A versus 5.90 months [range: 0.06-27.6] (p=ns) in Group B. Complication rate was 15.9% in Group A versus 8.9% in Group B corresponding to a complication rate per patient-implantation-days of 0.66/1000 patient-days (A) versus 0.42/1000 patient-days (B). Premature port device explantation rate was 4.4% (A) versus 5.4% (B). Axillary and subclavian venous thrombosis was the main complication and occurred in 12 Group A patients and three Group B patients. Venous thrombosis rate was 0.37/1000 patient-days (A) and 0.13/1000 patient-days (B) (p=0.03)., Conclusions: A few data exist about device insertion in HNP in whom venous cervical access is contraindicated. This comparative study demonstrates that both implantation techniques are safe and effective. The higher technical success rate with 0% heavy sedation, the lower venous thrombosis rate in the API group, and the 5.3% (A-B) patient transfer rate argue in favour of arm port placement in HNP. Indications for API include patients with an ipsilateral major pectoralis-myocutaneous flap, with radiodermatitis, tumour recurrence in the neck and upper chest, or with respiratory impairment.

After 3D conformal radiation therapy without and with modulated intensity, image-guided radiation therapy represents a new technological step. Should prostate cancer treatment using radiotherapy with the CyberKnife robotic system be considered as a new treatment and then investigated through classical clinical research procedure rather than a technical improvement of an already validated treatment? After a general presentation of the CyberKnife , the authors focused on prostate cancer treatment assuming that, according to dosimetric and biological considerations, the treatment by robotic system appears comparable to high dose rate brachytherapy. For prostate cancer treatment are discussed: biological rational for hypofractionated treatment, high dose rate brachytherapy boost and interest of dose escalation. A comparison is presented between CyberKnife and other validated treatment for prostate cancer (radical prostatectomy, 3D conformal radiation therapy and low and high dose rate brachytherapy). In summary, CyberKnife treatment could be considered as a technical improvement of an already validated treatment in order to deliver a prostate boost after pelvic or peri-prostatic area irradiation. However, the clinical, biological and economical results must be precisely analyzed and could be assessed in the frame of a National Observatory based on shared therapeutic program.

Introduction: Standard treatment is achieving good local control for rectal cancer. Innovative approach is aiming at increasing conservative treatment., Methodology: Strong evidence relies on randomized trials. Phase I and II trials are the method to evaluate advances., Results: Preoperative radiotherapy with concurrent chemotherapy is the standard treatment for most of the T3 (4) tumors. To increase conservative treatment innovative neoadjuvant treatment achieving complete clinical response is a promising approach., Conclusion: Well-conducted clinical trials are improving the standard treatments and are evaluating new hypotheses.

Cancers of the upper aerodigestive tract cover the solid tumors of the oral cavity, pharynx and larynx. The principal risk factors identified are smoking and alcohol. Moreover, the combination of alcohol and smoking increases the relative risk by more than simple multiplication. The pretreatment work-up represents the starting point in the natural history of the patient's disease and conditions recovery and time course; it must be both specific and exhaustive. It leads to a TNM classification or staging that is a major prognostic factor and essential to determination of the appropriate therapy. Patients with cancer of the upper aerodigestive tract must receive cooperative multidisciplinary treatment. Conservative treatment strategies must be favored. Treatment is essentially surgical and radiological. Prognosis for survival is poor. For all stages and sites together, 5-year survival remains between 30 and 40%.

Purpose: Intra-operative intertitial brachytherapy has been applied in the curative and palliative treatment of lung cancer. Implantation of radio-active sources offers an advantage over external irradiation because of the limited penetrability from source to prescription point, resulting in rapid dose fall-off and sparing of surrounding normal tissues. The aim of this study was to re-evaluate retrospectively the Antoine-Lacassagne cancer center experience in endobronchial brachytherapy by low dose rate (LDR) or high dose rate (HDR) and to design perspectives for the next decades. Evaluation was based on analysis of toxicities, response rates and survival., Materials and Methods: From october 1989 to june 1999, 31 consecutive patients with bronchogenic carcinoma were treated. Thirteen and 18 patients received LDR and HDR, respectively. The mean age was 65 years (range 44 to 79 years). Inclusion criteria were, for palliative treatment, incurable endobronchial cancer, and for curative treatment, residual tumor in the margins after resection, or endobronchial tumor could not be treated surgically. Exclusion criteria were sites of lesion unsuitable for placement of the brachytherapy catheter. Evaluation of complications and clinical response were based on endoscopic evaluation one month after the last session and at less one year after the end of treatment., Results: Eighty-seven courses have been performed: 65 by LDR and 22 by HDR. Thirty-six courses have been performed in the palliative group, 51 courses in the curative group. Seven patients among 31 presented acute complications and 18/31 late complications. Complete global response rate was 14/30 evaluable patients (47%). Mean overall global survival was 23 months with a median follow-up of 3.5 years., Conclusion: These results confirm the efficacy of endobronchial brachytherapy as well as palliative or curative treatment, but the improvement of results will essentially depend on our capacity to better define our indications and underlie the necessity to perform phase III international randomised trial.

Use of the low-energy helium-neon laser (LEL) appears to be a simple atraumatic technique for the prevention and treatment of mucositis of various origins. Preliminary findings, and significant results obtained for chemotherapy-induced mucositis in a previous phase III study, prompted a randomized multicenter double-blind trial to evaluate LEL in the prevention of acute radiation-induced stomatitis. Irradiation by LEL corresponds to local application of a high-photon-density monochromatic light source. Activation of epithelial healing for LEL-treated surfaces, the most commonly recognized effect, has been confirmed by numerous in vitro studies. The mechanism of action at a molecular and enzymatic level is presently being studied. From September 1994 to March 1998, 30 patients were randomized. Technical specification: 60 mW (25 mW at Reims, 1 patient), He-Ne, wavelength 632.8 nm. The trial was open to patients with carcinoma of the oropharynx, hypopharynx and oral cavity, treated by radiotherapy alone (65 Gy at a rate of 2 Gy/fraction, 5 fractions per week) without prior surgery or concomitant chemotherapy. The malignant tumor had to be located outside the tested laser application areas (9 points): posterior third of the internal surfaces of the cheeks, soft palate and anterior tonsillar pillars. Patients were randomized to LEL or placebo light treatment, starting on the first day of radiotherapy and before each session. The treatment time (t) for each application point was given by the equation : t(s)= energy (J/cm2) x surface (cm2)/Power (W). Objective assessment of the degree of mucositis was recorded weekly by a physician blinded to the type of treatment, using the WHO scale for grading of mucositis and a segmented visual analogue scale for pain evaluation. Protocol feasibility and compliance were excellent. Grade 3 mucositis occured with a frequency of 35.2% without LEL and of 7.6% with LEL (P<0.01). The frequency of "severe pain" (grade 3) was 23.8% without LEL, falling to 1.9% with LEL (P<0.05). Pain relief was significantly reduced throughout the treatment period (weeks 2-7). LEL therapy is capable of reducing the severity and duration of oral mucositis associated with radiation therapy. In addition, there is a tremendous potential for using LEL in combined treatment protocols utilizing concomitant chemotherapy and radiotherapy.

Primary cerebral lymphoma is a rare disease with an unfavorable prognosis. Whole brain radiotherapy has been the standard treatment, but neither the optimal radiation fields nor optimal dose level of the regimen are as yet firmly established. From this review of the literature, it seems that the whole brain must be treated, and a boost to the area of the primary site must be discussed. With regard to dose, the radiation dose-response relationship is not clearly proven. Yet, a minimum dose of 40 Gy is necessary, and the maximum dose is set at 50 Gy because of late neurological sequelae. Because of the poor prognosis of this disease and the risk of late sequelaes, other avenues have been explored. Chemotherapy has been studied, seem to have a survival advantage and combinations of radiotherapy and chemotherapy, especially with high-dose methotrexate. Because primary cerebral lymphoma is an uncommon disease, randomized clinical trials that compare radiotherapy alone to chemotherapy plus radiotherapy may not be feasible. Finally, even if chemotherapy seems to have a survival advantage, the regimen of chemotherapy is still a matter of debate.