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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.

Riassunto I dispositivi endovenosi sono divenuti strumenti imprescindibili nella gestione dei pazienti e hanno notevolmente migliorato la loro qualita di vita. Negli ultimi anni e cresciuta l’offerta di diverse tipologie di dispositivi adatti all’uso a breve, a medio o a lungo termine. La scelta del tipo di dispositivo che soddisfa una serie di raccomandazioni deve essere concordata tra l’equipe curante e il paziente e non deve obbedire solo ai vincoli organizzativi. La qualita delle cure, sia per l’installazione che per la manutenzione, e garanzia di sicurezza del paziente e del suo futuro vascolare, oltre che della longevita dei dispositivi e della prevenzione del rischio di complicanze. Le strategie preventive delle complicanze, spesso comuni ai diversi tipi di dispositivi, si basano su consensi digestione che derivano dalla medicina basata sull’evidenza e su una politica di formazione per operatori sanitari e pazienti. L’antisepsi cutanea si e recentemente evoluta. Le tecniche ecografiche per il posizionamento percutaneo devono essere generalizzate e continuare a beneficiare di progressi costanti. La posizione dell’estremita distale del catetere alla giunzione tra atrio destro e vena cava superiore resta la pietra angolare della prevenzione della trombosi. I trattamenti conservativi, cosi come l’uso di blocchi preventivi o curativi, sono oggetto di crescente interesse per evitare ablazioni inutili, traumatiche e costose. Le complicanze meccaniche e ostruttive e gli stravasi sono sempre meglio studiati e padroneggiati. La ricerca e attiva e richiede molteplici competenze sia nel campo delle infezioni e del biofilm che nel campo della trombosi e dei materiali e delle superfici, associando ricercatori, chimici, industriali e operatori sanitari. La cooperazione interprofessionale e in forte espansione, il che giustifica una riflessione sull’esistenza di unita ospedaliere dedicate all’installazione e alla manutenzione dei dispositivi endovenosi.

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.

Los dispositivos intravenosos se han convertido en herramientas esenciales para el tratamiento de los pacientes y han mejorado considerablemente su calidad de vida. El suministro de diferentes tipos de dispositivos adecuados para usos a corto, medio o largo plazo ha aumentado en los ultimos anos. La eleccion del tipo de dispositivo, que responde a una serie de recomendaciones, debe acordarse entre el equipo de atencion medica y el paciente, y no debe estar limitada solo por exigencias organizativas. La calidad de la atencion, tanto para la colocacion como para el mantenimiento, garantiza la seguridad del paciente y su futuro vascular, asi como la duracion de los dispositivos y la prevencion del riesgo de complicaciones. Las estrategias preventivas para las complicaciones, que a menudo son comunes a los diferentes tipos de dispositivos, son producto de consensos de tratamiento basados en la evidencia y en una politica de capacitacion del personal sanitario y de los pacientes. La antisepsia cutanea ha evolucionado recientemente. Las tecnicas ecograficas de apoyo para las colocaciones percutaneas deben generalizarse y continuar beneficiandose de un progreso constante. La posicion del extremo distal del cateter en la union de la vena cava superior con la auricula derecha sigue siendo la piedra angular de la prevencion de la trombosis. Los tratamientos conservadores, asi como el uso de sellados preventivos o curativos, son de creciente interes para evitar ablaciones innecesarias, traumaticas y costosas. Las complicaciones, mecanicas y obstructivas, y las extravasaciones se estudian y controlan cada vez mejor. La investigacion es activa y requiere experiencia multiple en el campo de la infeccion y la biopelicula, asi como en el campo de la trombosis y los materiales y superficies, con la participacion de investigadores, quimicos, industriales y personal sanitario. La cooperacion interprofesional esta en auge, lo que justifica una reflexion sobre la existencia de unidades hospitalarias dedicadas a la colocacion y el mantenimiento de dispositivos intravenosos.

I dispositivi endovenosi sono divenuti strumenti essenziali nella gestione dei pazienti e hanno notevolmente migliorato la loro qualita di vita. L’offerta di diversi tipi di dispositivi adatti a impieghi a breve, a medio o a lungo termine e aumentata negli ultimi anni. La scelta del tipo di dispositivo, che risponde a una serie di raccomandazioni, deve essere concordata tra l’equipe curante e il paziente e non deve obbedire unicamente a vincoli organizzativi. La qualita delle cure, sia per il posizionamento che per la manutenzione, e garanzia della sicurezza del paziente e del suo futuro vascolare, nonche della longevita dei dispositivi e della prevenzione del rischio di complicanze. Le strategie preventive delle complicanze, spesso comuni ai diversi tipi di dispositivi, si basano su consensi di gestione basati sull’evidenza e su una politica di formazione di caregiver e pazienti. L’antisepsi cutanea si e recentemente evoluta. Le tecniche ecografiche per il posizionamento percutaneo devono essere generalizzate e continuano a beneficiare di progressi costanti. La posizione dell’estremita distale del catetere alla giunzione tra atrio destro e vena cava superiore rimane la pietra angolare della prevenzione della trombosi. I trattamenti conservativi, cosi come l’uso di bloccaggi preventivi o curativi, sono oggetto di crescente interesse per evitare ablazioni inutili, traumatizzanti e costose. Le complicanze meccaniche e ostruttive, come gli stravasi, sono studiate e padroneggiate sempre meglio. La ricerca e attiva e richiede molteplici competenze nel campo dell’infezione e del biofilm, nonche nel campo della trombosi, dei materiali e delle superfici, coinvolgendo ricercatori, chimici, industriali e operatori sanitari. La cooperazione interprofessionale e in piena espansione, il che giustifica una riflessione sull’esistenza di unita ospedaliere dedicate al posizionamento e alla manutenzione dei dispositivi endovenosi.

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.

L’osteoradionecrosi (ORN) e una complicanza legata alla radioterapia della cavita orale o dell’orofaringe. Il rischio di ORN e piu frequentemente post-traumatico sulla mandibola che sulla mascella e persiste anche dopo molti anni dall’irradiazione. Questo rischio dipende dalla dose e persiste nonostante i cambiamenti nelle tecniche di irradiazione e il loro potenziale di preservazione della secrezione salivare e di limitazione della dose trasmessa all’osso di sostegno. La prevenzione consiste nell’evitare terapie dentarie invasive e nell’attuare una fluoroprofilassi finche resta insufficiente il recupero salivare. Il trattamento medico precoce viene realizzato a scopo antifibrosante, anti-infiammatorio e anti-infettivo e si associa a tecniche di detersione dei tessuti necrotici, ma non deve, comunque, ritardare il ricorso a un trattamento radicale.

Resume Les spondyloarthrites constituent un groupe de maladies rhumatismales dont le point commun est l’atteinte du rachis et des articulations sacro-iliaques (ASI). Un diagnostic precoce est requis pour une prise en charge therapeutique precoce et un meilleur pronostic. Les nouvelles molecules, en particulier anti-TNF alpha ont fait la preuve de leur efficacite dans le controle de l’inflammation et la prevention de l’evolution vers l’ankylose. L’imagerie permet actuellement un diagnostic plus precoce, en particulier l’imagerie par resonance magnetique (IRM) du rachis et des ASI.

L’osteonecrosi dei mascellari (ONM) sotto bifosfonati (BP) e secondaria a una sostanza farmacologica che modifica il rimodellamento osseo. L’incidenza di ONM in pazienti trattati con BP per affezioni maligne varia dall’1% al 10%, e dallo 0,001% allo 0,1% in caso di affezione benigna. Questo rischio e maggiore per via endovenosa che per via orale e aumenta con la durata della somministrazione. Tutto cio richiede di ridurre l’infiammazione e l’infezione locale attraverso misure di detersione parodontale (rimozione del tartaro, lucidatura) preliminarmente alla realizzazione di interventi chirurgici (con collutorio e antibioticoprofilassi). Il posizionamento di impianti dentari non e raccomandato nei pazienti in terapia con BP per via endovenosa nel quadro di patologie maligne. Il posizionamento di impianti e possibile nei pazienti con osteoporosi trattata con BP orali, dopo un’attenta valutazione del rischio. La gestione dei pazienti a rischio di sviluppare ONM da BP richiede una stretta collaborazione del medico che prescrive BP con il dentista, cosi come un rigoroso controllo dentario prima della terapia durante e dopo.

Resume Le diagnostic du nodule thyroidien repose sur l’echographie et la classification TIRADS (Thyroid Imaging-Reporting and Database System), qui stratifie le risque de malignite en fonction des criteres echographiques. Il en decoule une prise en charge dont la cytoponction echoguidee est la pierre angulaire. Cette derniere permet de classer le nodule thyroidien en six categories cytologiques associees a un risque de cancer et a une conduite a tenir diagnostique et therapeutique selon la classification de Bethesda 2010. Differents pieges de l’echographie thyroidienne, source de faux positifs ou de faux negatifs de diagnostic de cancer thyroidien, sont revus dans cet article.

Resume L’aspect macroscopique du carcinome papillaire de la thyroide reflete la presence de papilles tumorales microscopiques et suggere une organisation fractale ou chacune des parties ressemble a l’ensemble, mais de maniere trop irreguliere pour etre decrite en geometrie Euclidienne. La connaissance de l’organisation microscopique du carcinome papillaire de la thyroide aide a comprendre la semiologie echographique et a selectionner les nodules devant faire l’objet d’une cytoponction diagnostique.

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 30 Gy in 10 fractions or 40 Gy 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 6 months 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.

Background Hereditary hemorrhagic telangiectasia (HHT) and hepatopulmonary syndrome are disorders characterized by the development of multiple pulmonary arteriovenous malformations (PAVM). Presentation of the hypothesis COX2 may be at the origin of a cascade of pro inflammatory events to favour angiogenesis and PAVM development. Testing the hypothesis HHT and hepatopulmonary syndrome mouse models may be used to show its effects on PAVM formation. Anti COX-2 therapy could also be tested in human individuals, particularly in patients presenting a hepatopulmonary syndrome or HHT with small PAVM. Implication of the hypothesis PAVMs are one of the main causes of morbidity in patients presenting with HHT disease, owing to the risks of rupture as well as paradoxical embolism exposing to stroke and/or cerebral abscess. Percutaneous embolization has become the treatment of choice of PAVM. Anti COX2 may prevent from PAVM development and subsequent related complications and avoid either surgery and/or percutaneous embolization and thus subsequent related complication.

International audience; Imaging records are an essential part of the overall management of patients due to undergo invasive interventional radiology (IR) or surgery. Imaging is needed for diagnosis, to confirm operability, plan the procedure, and as a per-operative guide [1]. In both IR and surgery, it is essential to be able to visualise and manipulate images from the workstation [2,3]. Current solutions, including the use of the PACS in operating theatres, are completely inadequate. The practice has become routine in interventional CT and the main manufacturers offer dedicated equipment to work with the imaging instrument and images [4]. The interface which offers the most is the use of a joystick to move the cursor on the screen in the same way as the conventional mouse. Manipulation, however, is imprecise and makes it slow and frustrating to use. Telecommand is easier to use but does not allow complex interactions. In reality, once the operator is under sterile conditions, working with pre-and per-operative imaging becomes extremely limited. In complex situations, it requires a third party (loading previous imaging, MR or PET-CT displays, multi-planar reformatting, zooming in onto an area of interest, etc.) sometimes leading to loss of concentration and loss of time [5].

The treatment of carcinomas of unknown primary revealed by cervical lymphadenopathy is based on neck dissection and nodal and pan-mucosal irradiation to control the neck and avoid the emergence of a metachronous primary. The aim of this review was to assess diagnostic and therapeutic approaches and criteria that may be used for a customized selective approach to avoid severe toxicities of pan-mucosal irradiation. A literature search was performed with the following keywords: cervical lymphadenopathy, unknown primary, upper aerodigestive tract, cancer, radiotherapy, squamous cell carcinoma, variants. The diagnostic workup includes a head and neck scanner or MRI, ((18)F)-FDG PET CT, a panendoscopy and tonsillectomy. Squamous cell carcinoma represents over two thirds of cases. The number of metastatic cervical nodes, nodal level, and histological variant (associated with HPV/EBV status) may determine the primary site origin and might be weighted for the determination of radiation target volumes on a multidisciplinary basis. A selective customized approach is relevant to decrease radiation toxicity only if neck and mucosal control is not impaired. Although no recommendation can yet be made in the absence of sufficient level of evidence, the relevance of systematic pan-mucosal irradiation appears questionable in a number of clinical situations. Accordingly, a customized selective redefinition of target volumes may be discussed and be prospectively evaluated in relation to the therapeutic index obtained.

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.

Resume La telangiectasie hemorragique hereditaire (THH), ou maladie de Rendu-Osler-Weber, est une maladie autosomique dominante, qui se caracterise par la presence de malformations arterio-veineuses cutanees, muqueuses et/ou viscerales multiples. Les malformations arterio-veineuses pulmonaires (MAVP) comportent un risque de rupture, source d’hemoptysies ou d’hemothorax parfois mortels. Les MAVP representent un shunt droit-gauche vrai a l’origine d’embolies paradoxales engendrant AVC ou abces encephaliques. Le depistage doit etre systematique compte tenu du taux de complications spontanees approchant les 50 %. Le taux de complications neurologiques est considerablement plus eleve chez les patients presentant une atteinte pulmonaire diffuse. Le diagnostic de MAVP repose principalement sur l’echocardiographie transthoracique de contraste (ECTT) et la tomodensitometrie (TDM). La TDM permet egalement de planifier la strategie therapeutique, l’embolisation par occlusion percutanee ayant supplante la chirurgie dans la plupart des cas. La technique de l’ancrage consiste a securiser le geste d’embolisation de la MAVP en bloquant les premiers centimetres de la premiere spirale metallique dans une petite branche collaterale de l’artere afferente, juste en amont du sac anevrismal. Elle previent ainsi la migration accidentelle de la spirale dans la circulation gauche. La TDM avec injection de produit de contraste iode est l’examen de reference pour le controle de choix pour identifier la reprise, la persistance d’un flux ou l’augmentation de taille de la MAVP, indiquant les divers mecanismes de reperfusion des MAVP. Entre des mains entrainees, l’embolisation percutanee des MAVP en premiere intention est un traitement sur, efficace et durable pour la majorite des patients atteints de THH.

Resume L’objectif de cette revue iconographique est de decrire la semiologie thoracique en tomosynthese. Nous rapportons quelques exemples de cas ou la tomosynthese peut etre avantageusement comparee a la radiographie standard et/ou au scanner thoracique. La tomosynthese, effectuee a l’aide d’une simple table de radiologie haut de gamme, permet de disposer rapidement de nombreuses coupes thoraciques, avec une excellente resolution spatiale et une faible exposition aux rayons X.

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.

Resume Objectif L’objectif principal de notre etude etait de determiner les facteurs pronostiques cliniques et histologiques des cancers localement avances de la cavite buccale traites par chirurgie premiere. Methodes Nous avons mene une etude retrospective portant sur l’ensemble des patients ayant eu une chirurgie premiere avec reparation par lambeaux libres, pour un carcinome epidermoide localement avance de la cavite buccale, dans notre institution, entre 2000 et 2010. Les survies globales, specifiques et sans recidive locoregionale ont ete determinees par la methode de Kaplan-Meier. Les facteurs pronostiques cliniques et histologiques ont ete recherches en analyses uni- (tests du Log Rank) et multivariees (modeles de Cox). Resultats Au total, 149 patients (102 hommes et 47 femmes), d’âge moyen egal a 61,3 ± 12,1 ans ont ete inclus dans notre etude. Les survies globales, specifique et sans recidive locoregionale etaient respectivement de 55, 68 et 71 % a cinq ans. L’âge, la comorbidite et la taille tumorale (sur coupes histologiques) ont ete correles de facon statistiquement significative a la survie globale (p Conclusion Les principaux facteurs pronostiques retrouves dans notre etude etaient a la fois cliniques comme l’âge et la comorbidite des patients et histologiques comme la taille tumorale mesuree sur coupes anatomo-pathologiques, l’envahissement osseux et les limites d’exerese chirurgicale.

Resume Objectif Le traitement standard des lesions osseuses douloureuses localisees repose actuellement sur la radiotherapie, technique comportant des insuffisances. Notre etude vise a demontrer que la cimentoplastie constitue un traitement palliatif efficace des lesions de siege extrarachidien. Patients et methode Nous avons effectue le suivi prospectif de 20 patients ayant recu une cimentoplastie percutanee sur lesions osseuses lytiques douloureuses entre mai 2008 et mai 2010. Chez 17 patients, la douleur rendait la marche difficile. L’indication clinique du traitement etait une douleur severe (≥ 4 sur l’echelle numerique) due a une lesion osseuse objectivee par la TDM ou l’IRM. Toutes les cimentoplasties (sauf une) ont ete realisees sous anesthesie locale Resultats La faisabilite etait de 100 % sans complications immediates. Les patients ont fait etat d’une diminution nette et rapide de la douleur (4,1 points, p Conclusion Dans notre experience, la cimentoplastie percutanee peut constituer un traitement palliatif sur et efficace des lesions lytiques douloureuses localisees. Le controle alliant scanner et radioscopie semble l’option la plus sure en raison de la localisation extravertebrale. Le remplissage adequat de l’os et la selection rigoureuse des patients conditionnent l’efficacite du geste. Les lesions douloureuses diffuses et les diaphyses des os longs ne sont pas de bonnes indications.

PurposeThe 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.MaterialsSeventeen 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.ResultsFeasibility was 100% without immediate complications. The patients experienced a significant and rapid decrease of their pain (4.1 points, P

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.

Summary 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 5 mm was associated with a higher risk of recurrence (P = 0.008). Conclusion Tumour multifocality does not appear to have a prognostic impact in PTMC.

Resume Objectif Le but de notre etude est d’evaluer l’impact pronostique de la multifocalite tumorale dans le cadre des microcarcinomes papillaires (MCP) de la glande thyroide. Methodes Nous avons mene une etude retrospective portant sur l’ensemble des patients operes d’une thyroidectomie totale avec evidement du compartiment central (ECC) pour un MCP entre 1990 et 2007 au sein de notre institution. Nous avons recherche en analyses uni- et multivariees une correlation statistique entre la multifocalite tumorale et divers parametres cliniques et histologiques determinants du pronostic. Resultats Au total, 160 patients (133 femmes et 27 hommes) d’âge moyen egal a 47,8 ± 13,7 ans ont ete inclus dans notre etude. Une multifocalite tumorale a ete retrouvee chez 59 (37 %) patients. Un envahissement ganglionnaire du compartiment central a ete identifie chez 46 (28 %) patients. Il n’a pas ete retrouve de correlation statistique entre la multifocalite tumorale et les facteurs suivants : âge, sexe, taille tumorale, extension extrathyroidienne, envahissement ganglionnaire initial du compartiment central et risque de recidive. Une taille tumorale superieure a 5 mm a ete associee a un risque plus eleve de recidive (p = 0,008). Conclusion La multifocalite tumorale ne semble pas avoir d’impact pronostique dans les MCP de la glande thyroide.

Resume Le syndrome cave superieur (SCS) regroupe l’ensemble des signes secondaires a l’obstruction du drainage veineux cave superieur et a l’elevation de la pression veineuse dans les territoires situes en amont. Il existe deux grandes causes de SCS : malignes dominees par le cancer bronchopulmonaire, et benignes souvent secondaires a la presence de dispositifs veineux implantables mal positionnes. Le scanner est l’examen cle pour l’exploration du SCS. Il permet de preciser les caracteristiques de la stenose, son etiologie et de mettre en evidence les voies veineuses collaterales. Les reconstructions scannographiques procurent une veritable cartographie de l’obstacle, indispensable a la planification du traitement endovasculaire.

Resume Les nouvelles techniques d’irradiation permettent de mieux conformer la dose aux contours de la tumeur. Le corollaire est une exigence accrue de precision. Des etudes recentes d’intercomparaison de plans de traitement ont souligne la necessite d’une harmonisation des pratiques de contourage. Une approche plus consensuelle repose sur l’utilisation de modalites d’imagerie adaptees, des recommandations de groupes experts et des atlas de segmentation automatiques, une harmonisation des decisions dosimetriques passant par l’utilisation d’abaques exhaustifs pour les organes a risque, et d’indices pour le choix des plans de traitement optimaux. A un echelon de plus, des programmes d’assurance qualite et de partage des donnees passant par l’utilisation de transferts de donnees DICOM RT (reseaux d’images) sont mis en place. La combinaison de plusieurs techniques d’irradiation differentes (par exemple, radiotherapie conformationnelle par modulation d’intensite [RCMI] + boost en CyberKnife ® et reirradiations), permettant de mieux irradier les tumeurs, necessite une documentation des doses cumulees grâce a des logiciels de sommation de dose. Une reelle prise de conscience s’est faite ces dernieres annees dans le sens de l’amelioration de la qualite des traitements, du partage des donnees et de l’harmonisation des pratiques.

Discography test associated with the scanner (discoscanner) is an exam that has been a renewed interest in recent few years. Thanks to the emergence of new interventions such as disc prosthesis, the procedures require confirmation of the disc level to deal with and the origin of discogenic symptoms. The aim of this paper is to describe the techniques, challenges and tips as well as the interpretation of functional and morphological examination.

Resume Introduction Les schwannomes cervicaux sont des tumeurs benignes des nerfs peripheriques developpees exclusivement a partir des cellules de Schwann. L’atteinte du nerf sympathique cervical est relativement rare, et les auteurs en rappellent, a partir d’un cas, les signes radiologiques evocateurs ainsi que les caracteristiques histologiques. Le traitement de ces tumeurs est chirurgical. Presentation du cas Une patiente de 56 ans consultait pour une masse laterocervicale superieure gauche isolee, ancienne, mais accompagnee d’une gene pharyngee recente. Une tomodensitometrie cervicale mettait en evidence une masse vascularisee au temps retarde, retrostylienne refoulant l’axe jugulocarotidien en avant. Un examen cytologique non contributif conduisait a realiser une exerese chirurgicale de la masse par voie de cervicotomie. Il s’agissait d’une tumeur retro-jugulocarotidienne developpee aux depens du nerf sympathique cervical. L’analyse histopathologique concluait a un schwannome. Les suites operatoires etaient marquees par un syndrome de Claude-Bernard-Horner. Conclusion Le schwannome du sympathique cervical est une tumeur benigne rare, qui doit etre evoquee devant toute masse laterocervicale isolee. La tomodensitometrie preoperatoire est un examen de choix indispensable pour evoquer le diagnostic. Le traitement est chirurgical, afin de confirmer le diagnostic histologique. Un syndrome de Claude-Bernard-Horner postoperatoire confirme souvent l’atteinte du sympathique cervical.

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.

Resume Objectif de l’etude Le risque associe aux soins dentaires est un probleme de pratique quotidienne pour les radiotherapeutes et les chirurgiens dentistes. En cas d’extraction dentaire postirradiation, ce risque est correle avec la dose d’irradiation recue localement. La resolution du probleme, c’est-a-dire la documentation de la dose est fastidieuse (deux heures de delineation manuelle) et imprecise en l’absence d’outil de segmentation automatique dentaire. Materiel et methodes Un outil de segmentation automatique dentaire base sur une methode multi-atlas, Dentalmaps, a ete mis au point a partir d’une base de donnees de patients traites pour cancer de la tete et du cou. Resultats Cet outil informatique permet, simplement et rapidement, une estimation a 2 Gy pres, ce qui est tout a fait pertinent pour l’usage clinique a partir des consoles de planification de radiotherapie. Conclusion cet outil cree une interface entre chirurgiens dentistes et radiotherapeutes d’autant plus necessaire que les nouvelles techniques d’irradiation complexifient l’estimation visuelle de la dose (inhomogeneites, gradients abruptes). Il devrait permettre d’ameliorer la comprehension des complications dentaires et de l’osteoradionecrose.

Aims To assess the efficacy of surgery and high-dose split-course radiotherapy in sinonasal head and neck mucosal melanoma (SHNMM). Material and methods Between 1991 and 2006, 23 patients (median age 73 years, male:female ratio 0.4) with non-metastatic SHNMM underwent surgery and postoperative radiotherapy, two had exclusive radiotherapy. Radiotherapy consisted of three series of 18Gy (3×6Gy every other day for 1 week) with 3 week planned treatment breaks. Chi-squared tests, Kaplan–Meyer method and Log-rank test were used to assess prognostic factors for survival and local control. Results There were 20 nasal cavity tumours; 12 of these involved more than one sinonasal site. One patient (4%) had lymphadenopathies at diagnosis. Six SHNMMs (24%) were amelanotic. The median follow-up was 39 months. Fourteen patients had en bloc surgery, 16 underwent radiation (14 postoperative, two exclusive). Eleven patients had local relapse, three had regional relapse and three had bone or liver metastases. Five year local control was 49±12%. Five year overall and SHNMM-specific survival was 38±12% and 62±12%, respectively. Five patients were alive without disease after 5 years and three after 10 years. En bloc excision (tumour removed in one piece) was prognostic for survival. Conclusions En bloc surgery was a prognostic factor on outcomes for local control and survival in this series. Data from the literature have shown that postoperative radiation therapy improves local control. Most series were carried out with conventional fractionation. The effect of planned breaks (split-course radiotherapy) may be deleterious, as suggested in this series. Therefore, split-course radiotherapy cannot be recommended for SHNMM.

Summary Objectives The goals of this study is to evaluate and compare the irradiation received by the practitioner when performing percutaneous vertebroplasty or kyphoplasty guided by CT and fluoroscopy, for precise anatomical sites. Methods For each intervention, radiothermoluminescent dosimeters were carefully positioned on both orbitals, both hands, and both ankles of the practitioner. Results Twenty-four vertebroplasties were performed in 18 patients and nine kyphoplasties on seven patients. The anatomical site that is most exposed to radiation is the right hand. The two other sites subjected to irradiation are the left hand and the left orbital. This study demonstrates a significant correlation between the irradiation dose and fluoroscopy duration, reflecting both the quantity of primary-beam radiation and backscattered radiation. Conclusion The radiation dose to radiologist is more important for kyphoplasty procedures than vertebroplasty.

Transfacet screws may be useful for stabilizing segments reconstructed with bone graft or cages, the role of supplementary posterior fixation, particularly minimally invasive techniques such as transfacetar percutaneous screws is relevant. To benefit from a mechanical fixation after anterior arthrodesis without the inconveniences of the open classical posterior surgical intervention, we have developed a new procedure performed under local anesthesia and CT guidance and based on the intra-articular application of screws. This study was designed to demonstrate the feasibility of using a CT-scan to perform posterior arthrodesis of the spine under local anesthesia.

Ionizing radiation may interfere with electric components of pacemakers or implantable cardioverter-defibrillators. The type, severity and extent of radiation damage to pacemakers, have previously been shown to depend on the total dose and dose rate. Over 300,000 new cancer cases are treated yearly in France, among which 60% are irradiated in the course of their disease. One among 400 of these patients has an implanted pacemaker or defibrillator. The incidence of pacemaker and implanted cardioverter defribillator increases in an ageing population. The oncologic prognosis must be weighted against the cardiologic prognosis in a multidisciplinary and transversal setting. Innovative irradiation techniques and technological sophistications of pacemakers and implantable cardioverter-defibrillators (with the introduction of more radiosensitive complementary metal-oxide-semiconductors since 1970) have potentially changed the tolerance profiles. This review of the literature studied the geometric, dosimetric and radiobiological characteristics of the radiation beams for high energy photons, stereotactic irradiation, protontherapy. Standardized protocols and radiotherapy optimization (particle, treatment fields, energy) are advisable in order to improve patient management during radiotherapy and prolonged monitoring is necessary following radiation therapy. The dose received at the pacemaker/heart should be calculated. The threshold for the cumulated dose to the pacemaker/implantable cardioverter-defibrillator (2 to 5 Gy depending on the brand), the necessity to remove/displace the device based on the dose-volume histogram on dosimetry, as well as the use of lead shielding and magnet are discussed.

International audience; INTRODUCTION: New radiation therapy techniques seek to adapt dose distribution to three-dimensional tumor geometry, so as to deliver the lowest possible dose to normal tissue and at-risk organs. This is expected to enhance locoregional control and survival and to reduce complications and thereby improve quality of life. Post-radiation xerostomia significantly deteriorates quality of life. MATERIAL AND METHODS: New external radiation techniques (such as intensity-modulated conformal radiation therapy, RapidArc VMAT arc therapy, tomotherapy, CyberKnife(®), protontherapy, use of carbon ions) applicable in ENT are reviewed. RESULTS: Preliminary data show interesting results in terms of salivary function with highly conformal techniques. CONCLUSION: In France, assessment is ongoing, financed under the Health Ministry's "Support for Expensive Innovatory Techniques" scheme (STIC [Soutien aux techniques innovantes coûteuses]), as routine use is growing rapidly.

Resume Introduction Le but des nouvelles techniques d’irradiation est d’adapter la distribution de la dose a la geometrie de la tumeur dans les trois dimensions de l’espace, en delivrant la dose la plus faible possible aux tissus normaux et aux organes a risque. Les corollaires attendus sont d’ameliorer le controle locoregional et la survie, de limiter les complications et ainsi d’ameliorer la qualite de vie. La xerostomie post-radique altere significativement la qualite de vie. Materiel et methodes Les nouvelles techniques d’irradiation externe (comme l’irradiation conformationnelle par modulation d’intensite, l’arctherapie RapidArc/VMAT, la tomotherapie, le Cyberknife ® , la protontherapie, l’utilisation des ions carbone) applicables en ORL sont passees en revue. Resultats Les nouvelles techniques d’irradiation ont un potentiel de preservation salivaire a controle carcinologique equivalent. Conclusion Une evaluation est en cours sous forme de soutien aux techniques innovantes couteuses (STIC) en France d’autant que leur utilisation est rapidement croissante en routine.

Basaloid squamous cell carcinoma (BSCC) is a rare variant of squamous cell carcinoma (SCC) of the head and neck. Wain's criteria (peripheral palisading, association with SCC, high nuclear-cytoplasmic ratio, high mitotic rate, solid growth), anti-34BE12 and CK 5/6 staining, and absence of neuroendocrine markers are mandatory for the diagnosis of BSCC. Its increasing incidence parallels that of human papilloma virus (HPV)-positive tumours for the oropharyngeal subsite. On the other hand, BSCC is frequently considered a high-grade carcinoma of poorer prognosis than its SCC counterparts, mostly due to a higher rate of distant metastases. However, BSCC has similar or better locoregional control rates and a relatively better radiosensitivity than SCC. BSCC seems to have a dual behaviour depending, at least partly, on its recently described association with HPV. The basaloid subtype of SCC, owing to its particular behaviour, should be systematically investigated along with HPV and smoking status, as those factors may be determinant in the response to treatment.

Cyberknife (Accuray Inc. Sunnyvale, USA) stereotactic body radiation therapy (SBRT) involves the delivery of a small number of large doses of radiation to a target volume using continuously evolving advanced technology. It has emerged as a novel treatment modality for cancer and modified some concepts of cancer treatment. It is indicated in early-stage primary cancer, sometimes as an alternative to surgery. It is also indicated for patients with oligometastatic disease who have relatively long survival with the aim to optimize disease control with a good quality of life. Although there remain some uncertainties regarding the radiobiology of hypofractionation, local control and tolerance have been promising. Indications are increasing under strict quality assurance programs worldwide and prospective clinical evaluation.

Pre-irradiation dental care depends on teeth health, fields and dose of irradiation, compliance to fluorides, cessation of tobacco and psychosocial cofactors. Dental care aims at preventing complications and preserving the quality of life (eating, speech and aesthetics). Approximately 11% of patients do not require any pre-irradiation dental care. Dental complications vary from slight colorations of the teeth to major complication such as osteoradionecrosis. Osteoradionecrosis rates vary from 1 to 9%, and may be decreased by using a 21-day delay between extractions and irradiation, provided that it does not postpone cancer treatment, with a dose-dependent risk ( or =20% if >60 Gy). Osteoradionecrosis occurs spontaneously (35%), mostly involves the mandibula (85%).

Pre-irradiation dental care depends on teeth health, fields and dose of irradiation, compliance to fluorides, cessation of tobacco and psychosocial cofactors. Dental care aims at preventing complications and preserving the quality of life (eating, speech, and aesthetics). The role of hyperbaric oxygenotherapy for the prevention of osteoradionecrosis after teeth removal on the mandibula in areas receiving 50 Gy or more is still controversial. Medical treatments may be sufficient for early stages of osteoradionecrosis (antibiotics, pain killers, non-steroidal anti-inflammatory drugs as well as clodronate, vitamin E, pentoxifyllin). However, reconstructive surgery should not be delayed in advanced stages of osteoradionecrosis. New irradiation techniques are changing dose distributions and therefore require close collaboration between odonto-stomatologists and radiation oncologists to define the best dental care.

The optimal timing and extent of neck dissection in the context of chemoradiation for head and neck cancer remains controversial. For some institutions, it is uncertain whether neck dissection should still be performed upfront especially for cystic nodes. For others, neck dissection can be performed after chemoradiation and can be omitted for N1 disease as long as a complete response to chemoradiation is obtained. The question is debated for N2 and N3 disease even after a complete response as the correlation between radiological and clinical assessment and pathology may not be reliable. Response rates are greater than or equal to 60% and isolated neck failures are less than or equal to 10% with current chemoradiation protocols. Some therefore consider that systematic upfront or planned neck dissection would lead to greater than or equal to 50% unnecessary neck dissections for N2-N3 disease. Positron-emission tomography (PET) scanning to assess treatment response and have shown a very high negative predictive value of greater than or equal to 95% when using a standard uptake value of 3 for patients with a negative PET at four months after the completion of therapy. These data may support the practice of observing PET-negative necks. More evidence-based data are awaited to assess the need for neck dissection on PET. Selective neck dissection based on radiological assessment and peroperative findings and not exclusively on initial nodal stage may help to limit morbidity and to improve the quality of life without increasing the risk of neck failure. Adjuvant regional radiation boosts might be discussed on an individual basis for aggressive residual nodal disease with extracapsular spread and uncertain margins but evidence is missing. Medical treatments aiming at reducing the metastatic risk especially for N3 disease are to be evaluated.