[Concomitant bifractionated radiotherapy and chemotherapy with cisplatin and 5-fluorouracil in locally progressive, non-resectable epidermoid carcinomas of the pharynx: ten years experience at the Antoine Lacassagne center]

PURPOSE

Patients suffering from locally advanced unresectable squamous cell carcinoma of the oropharynx and hypopharynx treated with radiotherapy alone have a poor prognosis. More than 70% of patients die within 5 years mainly due to local recurrences. The aim of this study was to evaluate retrospectively the Antoine Lacassagne Cancer Center's experience in a treatment by concomitant bid radiotherapy and chemotherapy. Evaluation was based on analysis of the toxicity, the response rates, the survival, and the clinical prognostic factors.

PATIENTS AND METHODS

From 1992 to 2000, 92 consecutive patients were treated in our single institution. All of them had stage IV, unresectable squamous cell carcinoma of the pharynx and they received continuous bid radiotherapy (two daily fractions of 1.2 Gy, 5 days a week, with a 6-h minimal interval between fractions). Total radiotherapy dose was 80.4 Gy on the oropharynx and 75.6 Gy on the hypopharynx. Two or three chemotherapy courses of cisplatin (CP)-5-fluorouracil (5FU) were given during radiotherapy at 21-day intervals (third not delivered after the end of the radiotherapy). CP dose was 100 mg/m2 (day 1) and 5-FU was given as 5-day continuous infusion (750 mg/m2/day at 1st course; 430 mg/m2/day at 2nd and 3rd courses). Special attention was paid to supportive care, particularly in terms of enteral nutrition and mucositis prevention by low-level laser energy.

RESULTS

Acute toxicity was marked and included WHO grade III/IV mucositis (89%, 16% of them being grade IV), WHO grade III dermatitis (72%) and grade III/IV neutropenia (61%). This toxicity was significant but manageable with optimised supportive care, and never led to interruption of treatment for more than 1 week, although there were two toxic deaths. Complete global response rate at 6 months was 74%. Overall global survival at 1 and 2 years was 72% and 50% respectively, with a median follow-up of 17 months. Prognostic factors for overall survival were the Karnofsky index (71% survival at 3 years for patients with a Karnofsky index of 90-100% versus 30% for patients with a Karnofsky index of 80% versus 0% for patients with a Karnofsky index of 60-70%, p = 0.0001) and tumor location (55% at 3 years for oropharynx versus 37% for panpharynx versus 28% for hypopharynx, p = 0.009).

CONCLUSION

These results confirm the efficacy of concomitant bid radiotherapy and chemotherapy in advanced unresectable tumor of the pharynx. The improvement in results will essentially depend on our capacity to restore in a good nutritional status the patients before beginning this heavy treatment.

Comparison between nasogastric tube feeding and percutaneous fluoroscopic gastrostomy in advanced head and neck cancer patients

Wasting is a major complication of advanced head and neck cancer and the aim of this study was to compare nasogastric tube feeding (NG) and percutaneous fluoroscopic gastrostomy (PFG) in these patients. The goal of these two methods of nutritional support was to improve or maintain the initial nutritional status during treatment. A total of 90 patients, all stage IV oropharynx or hypopharynx tumor, were reviewed from a prospective databank. All these patients were treated by concomitant chemotherapy and twice-daily continuous radiotherapy with no acceleration. Fifty patients were managed by PFG, and the rest by NG. Mechanical failure, duration of feeding, complications, nutritional evaluation and quality of life were analysed. Mechanical failure occurred in 32 of the 40 NG patients and in seven of the gastrostomy group. In the PFG group, 80% of patients conserved their nutritional support after the end of the radiotherapy, none patient in the NG group. In the PFG group, two presented a wound infection and six had aspiration pneumonia while in the NG group, 21 had aspiration pneumonia probably due to the NG tube (gastroesophageal reflux). The feeding methods were found to be equally effective at maintaining body weight and body mass index at time 1 (3 weeks) and at time 2 (6 weeks). Advantages were associated with PFG cosmesis, mobility and quality of life. PFG is a safe and effective method of providing enteral nutrition during treatment to patients with advanced head and neck cancer and offers important advantages over NG.

Systematic percutaneous fluoroscopic gastrostomy for concomitant radiochemotherapy of advanced head and neck cancer: optimization of therapy

Wasting is a major complication of advanced head and neck cancer. Concomitant chemotherapy and twice-daily continuous radiotherapy with no acceleration represents a promising treatment modality for these tumors, but increases the risk of mucositis. This report describes the results achieved with percutaneous fluoroscopic gastrostomy (PFG) and its impact on the quality of life of patients with head and neck cancer in terms of their nutritional status. A total of 50 stage IV tumors of the oropharynx and hypopharynx recorded in a prospective database were reviewed retrospectively. All patients were managed by PFG, which was found to be a safe and effective technique with no technical failures. PFG feeding resulted in a mean increase in body weight of 2.5 kg within 3 weeks. The body mass index (BMI) was maintained at 3 and 6 weeks. Minor complications occurred, but no major complications were noted. The overall procedure-related mortality rate was nil. Further prospective investigations are necessary to determine whether treatment of wasting improves patient survival.

Cost-benefit analysis of percutaneous interventional radiological procedures in cancer patients

The goal of this work was to evaluate the costs and benefits of percutaneous interventional radiological procedures (PIRP) in terminal cancer patients, from the perspective of the Radiodiagnostics Department. The subjects were 225 patients who underwent different kinds of treatments, such as placement of endovenous or urinary stents, percutaneous gastrostomy, alcoholization of metastatic disease, celiac plexus block, tumor embolization, and inferior vena caval filter. We retrospectively analyzed the consequences in terms of survival, quality of life and cost ratios and found that this study fully justifies the use of interventional radiology in palliative oncology: 60% and 40% of the patients, respectively, were still alive at 1 month and 3 months; the additional cost of PIRP procedures is low (< 12%) compared with the total cost of hospitalization.

[Thoughts on the role of celiosurgery in patients with major obesity]

Is coelioscopic surgery an interesting way in massive obese patients? This is well established concerning the post-operative benefit, with a decreased risk of pulmonary and thrombo-embolic complications. But technical difficulties are not well described, whereas we encountered some: incomplete retraction of intra-abdominal organs, weakness and hemorrhagic tendency of the tissues, and most of all an insufficient pneumoperitoneum in all patients preventing sometime the surgical procedure. We analyse those obstacles to propose solutions when the laparoscopic way seems better regarding to the post-operative risk. We study their predictive factors, the best one being the thickness of the abdominal anterior wall, whereas the body weigh is an inadequate factor.

Perfluoroctylbromide and hepatosplenic computed tomography. Preliminary clinical study

The preliminary results of perfluorocytlbromide (PFOB) emulsion when used as an intravenous contrast agent for hepatosplenic CT imaging in humans are reported. Ten patients were examined using dosages ranging from 1 to 2 g/kg. There was good clinical and biochemical tolerance. Diagnostic dose for liver enhancement seems to be at least 2 g/kg, whereas 1 g/kg was sufficient for splenic enhancement.

[Implantation of permanent cardiac pacing electrodes by the retropectoral transvenous approach. Results of a series of 152 cases]

When the cephalic vein is unsuitable for the introduction of pacing electrodes, the retropectoral veins near the external border of pectoralis major near its subclavian attachment, approached through the same incision, may provide a suitable alternative. It was not possible to catheterise the cephalic vein in 23,8% of 756 consecutive implantations of endocavitary pacing electrodes. The retropectoral veins were looked for in 172 cases and found and used in 159 cases (92,4%). This percentage of success increased to 97,6% in the latter 83 attempts. These veins are usually very distensible. No complications or accidents were recorded. The only disadvantage was the relatively long dissection time. The stability of the pacing electrodes with this approach was excellent as reoperation was only required in 3% of cases (2 displacements and 3 exit blocks or pericardial migrations). This approach is therefore practicable in the large majority of cases in which the cephalic vein cannot be used. The multiplicity of the retropectoral veins should allow the introduction of two electrodes if sequential atrioventricular pacing were to be chosen. In addition, this approach would be useful when an atrial pacing electrode is to be added to a preexisting ventricular pacing electrode and one hesitates to puncture the subclavian vein because of the risk of damaging the electrode already in place. When direct subclavian puncture is the technique of choice of the operator, the retropectoral veins may be used when the subclavian approach is contraindicated or impossible. In any case, denudation of the retropectoral veins leads to fewer incidents than when the latter approach is used.