[Impact of neck dissection in N2-3 oropharyngeal squamous cell carcinomas treated with definitive chemoradiotherapy: An observational real-life study]

PURPOSE

The purpose of this study was to assess the efficacy in terms of neck failure of an initial neck dissection before definitive chemoradiotherapy in N2-3 oropharyngeal squamous cell carcinomas, as well as the dosimetric impact and the acute and delayed morbidity of this approach.

MATERIALS AND METHODS

All patients consecutively treated between 2009 and 2018 with definitive chemoradiotherapy using intensity-modulated conformal radiotherapy (IMRT) for a histologically proven N2-3 oropharyngeal squamous cell carcinomas were retrospectively included. The therapeutic approach consisted of induction chemotherapy, followed by cisplatine-based chemoradiotherapy preceded or not by neck dissection. Neck dissection was discussed on a case-by-case basis in a dedicated multidisciplinary tumour board for patients with a dissociated response to induction chemotherapy, defined as a better response on the primary than on the node. Chemoradiotherapy without neck dissection was systematically performed in case of a major lymph node response to induction chemotherapy (decrease in size of 90% or more). Intensity-modulated radiotherapy using a simultaneous-integrated boost delivered 70Gy in 35 fractions on macroscopic tumour volumes, 63Gy on intermediate-risk levels or extra-nodal extension and 54Gy on prophylactic lymph node areas.

RESULTS

Two groups were constituted: 47 patients without an initial neck dissection (62.7%), and 28 patients with a neck dissection prior to definitive chemoradiotherapy (37.3%). Initial patient characteristics were not statistically different between the two groups. The median follow-up was 60.1months (range: 3.2-119months). Incidence of neck failure was higher in patients without neck dissection (P=0.015). The neck failure rate at 5years was 19.8% (95% confidence interval: 7.4-30.6%; P=0.015) without neck dissection versus 0% following neck dissection. All lymph node failures occurred in the planned target volume at 70Gy. Upfront neck dissection suggested a decrease in the mean dose received by the homolateral parotid gland (P=0.01), mandible (P=0.02), and thyroid gland (P=0.02). Acute toxicity of chemoradiotherapy after neck dissection suggested a reduction in grade≥3 adverse events (P=0.04), early discontinuation of concomitant chemotherapy (P=0.009) and feeding tube-dependence (P=0.008) in univariate analysis. During follow-up, there was no difference between the two groups in terms of xerostomia, dysgeusia, dysphagia or gastrostomy dependence in univariate analysis.

CONCLUSION

Neck dissection prior to definitive chemoradiotherapy in N2-3 oropharyngeal squamous cell carcinoma was associated with high neck control without additional mid and long-term morbidity.

[New concepts of medical consultation in oncology]

New concepts of medical consultations are currently disrupting the practice of medicine. The use of standardized questionnaires, or patient-reported outcome (PRO and ePRO) has already significantly changed the relationship between the physician and the patient. Telemedicine, or even automatic conversational agents, such as chatbots, are also providing more convenient access to care and medical information for many patients. These tools have a major impact in oncology, precisely because of the rising chronicity of the diseases the radiation oncologists treat. In this article, we provide a detailed analysis of these new concepts.

[Stereotactic pulmonary radiotherapy: Which machine?]

Stereotactic radiotherapy represents a fundamental change in the practice of radiotherapy of lung cancers. Despite the great heterogeneity of sites, techniques, and doses, most studies found a high local control rate, around 70 to 90% at 2 years, and reduced toxicity, around 5% of grade 3 at 2 years. Stereotactic radiotherapy can be realized either by a dedicated accelerator (CyberKnife^®) or by a conventional accelerator associated with specific systems. The two modalities deliver a very precise irradiation whose very good results published to date are similar. Some technical characteristics specific to each type of linear accelerator could guide the choice according to the target volume treated.

Effective delivery of palliative radiotherapy: A prospective study

PURPOSE

The main goal of palliative radiotherapy is to reduce patient's discomfort. But sometimes patients do not receive any benefits from this treatment because of rapid worsening of their general condition. This prospective monocentric study assessed the effective delivery of palliative radiotherapy.

MATERIALS AND METHODS

From 1st December 2015 to 29th February 2016, all consecutive patients receiving palliative radiotherapy in our hospital were included. The primary endpoint was the effective delivery of palliative radiotherapy according to the initial prescription (total dose, overall treatment time and fractionation). The secondary endpoints were the number of treatment breaks, the clinical benefit, the number of deaths and the delays for admission in the palliative care unit.

RESULTS

Fifty-nine patients were included and 64 treatments were analysed. The treatment sites were: bone (70.3%) and brain (21.9%). The treatment goals were: pain control only (43.8%), decompression only (21.9%), pain control and decompression (32.8%), haemostatic aim (1.6%). Palliative treatment was achieved in 57 cases (89%). Temporary interruption of the radiotherapy treatment was necessary in six cases (9.4%; three for medical reason, three for logistic reason). The main reason of permanent interruption was worsening of performance status (seven cases). Palliation of symptoms (complete or partial responses) was obtained in 44 cases (68.8%). Seven patients (11.9%) died during the month after the end of the treatment. No delay or cancellation for admission in the palliative care unit were observed.

CONCLUSION

Palliative radiotherapy was completed as originally planned in 51 cases (79.9%) with a clinical benefit for 44 cases (68.8%). Radiation therapy must not be neglected as a palliative treatment at the end-of-life.

[Stereotactic body radiotherapy: Prospective study to evaluate asthenia and quality of life]

PURPOSE

To evaluate prospectively asthenia and the quality of life in patients treated by stereotactic body irradiation and to determine their predictive factors.

METHODS AND MATERIALS

Quality of life was assessed by the EORTC QLQ-C30 and asthenia was evaluated with the Brief Fatigue Inventory (BFI), on the first day (T1), last day (T2) and 1-3 weeks after the end of treatment (T3).

RESULTS

Sixty-three patients were treated with stereotactic body irradiation from February 2017 to May 2017 and 41 were included in the analysis (22 patients excluded for lack of understanding, organization, psychologic disorders or refusal). The mean number of fractions was 5 (±2). The compliance to quality of life assessment was 98%, 95% was 81% at T1, T2 and T3, respectively. An increase of asthenia and a worsened quality of life were found in 12 (29%) and 14 (34%) patients between T1 and T2. Univariate analysis demonstrated a correlation between asthenia and quality of life were correlated with performans status (P=0.03 and 0.05 respectively), hemoglobin level (p=0.01 and 0.004), albumin level (P=0.01 and 0.06), distance between home and radiotherapy department (P=0.05 and 0.02). Multivariate analysis demonstrated a correlation between female gender (P=0.012), albumin level (P<0.001), distance over 25km (P<0.001) with asthenia, and albumin level (P=0.003), hemoglobin level (P=0.004) and previous chemotherapy (P=0.003) with quality of life. No influence of stereotactic body ratiotherapy parameters was seen.

CONCLUSION

Despite hypofractionation, stereotactic body radiotherapy induced asthenia and deterioration of quality of life.

[Siriade 2.0: An e-learning platform for radiation oncology contouring]

PURPOSE

In 2008, the French national society of radiation oncology (SFRO) and the association for radiation oncology continued education (AFCOR) created Siriade, an e-learning website dedicated to contouring.

MATERIAL AND METHODS

Between 2015 and 2017, this platform was updated using the latest digital online tools available. Two main sections were needed: a theoretical part and another section of online workshops.

RESULTS

Teaching courses are available as online commented videos, available on demand. The practical section of the website is an online contouring workshop that automatically generates a report quantifying the quality of the user's delineation compared with the experts'.

CONCLUSION

Siriade 2.0 is an innovating digital tool for radiation oncology initial and continuous education.

A cemented acetabular component with a reinforcement cross provides excellent medium-term fixation in total hip arthroplasty after pelvic irradiation

Conventional cemented acetabular components are reported to have a high rate of failure when implanted into previously irradiated bone. We recommend the use of a cemented reconstruction with the addition of an acetabular reinforcement cross to improve fixation.

We reviewed a cohort of 45 patients (49 hips) who had undergone irradiation of the pelvis and a cemented total hip arthroplasty (THA) with an acetabular reinforcement cross. All hips had received a minimum dose of 30 Gray (Gy) to treat a primary nearby tumour or metastasis. The median dose of radiation was 50 Gy (Q1 to Q3: 45 to 60; mean: 49.57, 32 to 72).

The mean follow-up after THA was 51 months (17 to 137). The cumulative probability of revision of the acetabular component for a mechanical reason was 0% (0 to 0%) at 24 months, 2.9% (0.2 to 13.3%) at 60 months and 2.9% (0.2% to 13.3%) at 120 months, respectively. One hip was revised for mechanical failure and three for infection.

Cemented acetabular components with a reinforcement cross provide good medium-term fixation after pelvic irradiation. These patients are at a higher risk of developing infection of their THA.

Cite this article: Bone Joint J 2015;97-B:177–84.

[Pacemaker, implanted cardiac defibrillator and irradiation: Management proposal in 2010 depending on the type of cardiac stimulator and prognosis and location of cancer]

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.

Detection of choroidal calcium by computed tomography scan quantitative computerized tomography: a clinically useful diagnostic tool

OBJECTIVE

Quantitative computerized tomography (QCT), a scanning method routinely used to classify tissues based on their radio density, was used to detect choroidal calcification.

DESIGN

Case reports.

PARTICIPANTS

Two patients with known or suspected choroidal calcium-choroidal osteoma (CO) and pseudoxanthoma elasticum (PXE) and five normal control subjects were assessed.

INTERVENTION

The CT scan of choroid, B-scan ultrasound, fluorescein angiography.

MAIN OUTCOME MEASURES

The QCT scan used to detect the presence of calcium based on a readout greater than 90.

RESULTS

Calcium was detected bilaterally, as predicted, in PXE, and in both eyes of CO, although only one eye had a clinically noted lesion. No control eye gave a scale readout consistent with calcium. No findings suggestive of calcium were noted with B-scan ultrasound or fluorescein angiography in PXE or CO.

CONCLUSION

The QCT can detect calcium in the choroid when B-scan ultrasonography and CT scan fine sectioning fail to identify calcium despite high clinical suspicion.

Poisson-like fluctuation patterns of revertants of leucine auxotrophy (leu-500) in Salmonella typhimurium caused by delay in mutant cell division

Leu+ mutants from Salmonella typhimurium leu-500 strain MA412 arise at high frequencies and mutant colonies appear over a broad range of time on selective plates. This observation suggested that these Leu+ mutants might be induced or "directed."= If such a mechanism was responsible, mutants should originate on selective plates rather than in the preceding culture in nonselective conditions and should give rise to Poisson-like fluctuation curves upon plating of sister cultures on selective medium. Poisson-like distribution profiles were indeed observed for Leu+ mutants of S. typhimurium MA412. However, an explanation for the observed Poisson-like fluctuation patterns without a need for selection-induced mutations was found. Microscopical analysis and cell mass/viable count measurements showed that the size of Leu+ mutant cells was often much larger than those of nonmutants. This size difference was a stable characteristic of a large proportion of Leu+ mutants, was observed both in stationary and growing culture and did not measurably affect the division rates of the cells in nutrient broth. As the transition from normal-sized nonmutant to oversized mutant cells during the nonselective culture phase of the fluctuation experiment may have been accompanied by a period with no or few completed cell division cycles, the number of mutant offspring may have been smaller than that of sibling nonmutants. Such underrepresentation of mutants in the final culture is expected to give rise to Poisson-like fluctuation patterns without invoking "directed" mutations.

Rapid method for purification of soil DNA for hybridization and PCR analysis

Monitoring of microbial DNA in soils by dot blot hybridization and PCR analysis is a useful technique for gaining insight into the survival and impact of genetically modified micro-organisms released in the environment. Most methods of DNA isolation from soils require a large number of purification steps rendering them unsuitable for quantitative analysis of multiple samples. Here we describe a very rapid method for the isolation and purification of multiple samples of soil DNA that can be used directly for dot blot hybridization and PCR analysis. Soil DNA extracts are prepared by lysozyme/SDS treatment at pH 9.0 and purified by ammonium acetate precipitation and Sephadex G50 gel filtration. In a practical application of this method, sandy soil samples were seeded with Alcaligenes eutrophus cells and exposed to high temperature (42 degrees C) or desiccation. As a result, the number of culturable A. eutrophus cells which could be recovered from the soil samples quickly declined. However, the concentration of a marker gene encoding resistance to cadmium, cobalt and zinc (czc) remained unaltered.

Synergistic toxicity of IFN-gamma-producing Escherichia coli K12 cells

Genetically modified microorganisms (GMMs) are frequently used as producers of mammalian immunomodulatory proteins, e.g. interferons and interleukins. Here we have examined the question of whether such GMMs interact in a way different from that of their non-modified parent micro-organisms with mammalian antimicrobial defence systems. As a typical GMM host micro-organism we used Escherichia coli K12, and as a typical immunomodulatory protein produced by a GMM we used mouse interferon-gamma (MuIFN-gamma). Two experimental systems are described in which synergistic "toxic" biological effects are induced by a combined treatment with E. coli and MuIFN-gamma but not, or less so, by the parental strain and the recombinant protein separately. First, it is shown that the IFN-gamma-producing GMM, or mixtures of E. coli cells and IFN-gamma, are cytolytic for mouse embryo fibroblastoid cells (MEF), whereas no cell killing occurs in MEF cultures treated with control E. coli cells or in those treated with bacteria-free recombinant IFN-gamma. Second, it is demonstrated that intraperitoneal injection in mice of high but not low numbers of control E. coli K12 cells induces a shock-like mortality, whereas co-injection with IFN-gamma induces killing at low numbers. IFN-gamma-producing E. coli cells cause a mortality rate that does not differ from that of control E. coli cells, probably because in these experimental conditions the level of recombinant MuIFN-gamma per cell is insufficiently high. Taken together, these data indicate that synergistic toxic effects induced by bacteria and their recombinant products can occur and may in certain situations enhance the intrinsic toxic capacity of the GMM. Synergistic toxic effects may thus be of relevance for identifying the safety level that should be employed when working with GMMs.

Identification of a catabolic transposon, Tn4371, carrying biphenyl and 4-chlorobiphenyl degradation genes in Alcaligenes eutrophus A5

Alcaligenes eutrophus A5 catabolizes biphenyl to CO2 via benzoate and 4-chlorobiphenyl to 4-chlorobenzoate. In curing and conjugation experiments, the A5 endogenous 51-kb IncP1 plasmid pSS50 was found to be dispensable for biphenyl and 4-chlorobiphenyl catabolism. Transfer of the biphenyl- and 4-chlorobiphenyl-degrading phenotype by means of pSS50 was observed at a frequency of 10(-5) per transferred plasmid in matings of A5 with other A. eutrophus strains. Transconjugants harbor enlarged pSS50 derivatives which contain additional genetic information governing the oxidation of biphenyl and 4-chlorobiphenyl to benzoate and 4-chlorobenzoate and originating from the chromosome of strain A5. The following observations indicate that the catabolic genes reside on a 59-kb large transposon (Tn4371) for which a restriction map is presented. (i) Tn4371 transposes between different replicons and at different locations of the same replicon. (ii) Transposition was observed in a Rec- strain of A. eutrophus. (iii) Tn4371 transposes as a single, contiguous piece of DNA. Although an RP4::Tn4371 plasmid was stably maintained in different hosts, the plasmid conferred growth on biphenyl only when present in strains of A. eutrophus and in an Acinetobacter sp. strain.

Construction and characterization of heavy metal-resistant haloaromatic-degrading Alcaligenes eutrophus strains

Alcaligenes eutrophus strains exhibiting both plasmid-borne heavy metal resistance and haloaromatic-degrading functions were obtained by intraspecific conjugation. The strains which we constructed expressed catabolic and resistance markers together. Degradation of various polychlorinated biphenyl isomers and 2,4-D (2,4-dichlorophenoxyacetic acid) was observed in the presence of 1 mM nickel or 2 mM zinc, provided that the metal resistance determinant was present in the catabolizing strain. Such strains may be useful for decontamination of sites that are polluted with both organic compounds and heavy metals.

Computerized tomography correlated with CSF protein concentrations

The authors present a case of hydrocephalus complicated by ventriculitis in which it was possible to correlate the numerical printout of sequential computerized tomograms (CT-Scans) with cerebrospinal fluid protein concentrations obtained by direct ventricular puncture. Different protein levels were unambiguously associated with changes in the absorption numbers on the scan but they did not bear a simple linear relationship to one another. The value of the numerical printout in diagnosis and follow-up is discussed.