Thariat Juliette, Leleu Thomas, Micault Emmanuel, Gery Bernard, Bastit Vianney, Jeanne Corinne, Humbert Maxime, Dugas Amaury, Le Guevelou Jennifer, Florescu Carmen, Patron Vincent, Lasne-Cardon Audrey, Babin Emmanuel
Centre François-Baclesse, département de radiothérapie, 3, avenue Général Harris, 14000 Caen, France.
Centre François-Baclesse, département de radiothérapie, 3, avenue Général Harris, 14000 Caen, France.
Bull Cancer. 2020 Jul-Aug;107(7-8):823-829. doi: 10.1016/j.bulcan.2020.04.011. Epub 2020 May 26.
Minimal invasive surgery and reconstructive surgery tend to become the standard in France in the management of head and neck tumors. The use of endoscopic approaches (through endoscopic endonasal/transoral approaches±robot-assisted) instead of open surgery and the use of reconstructive surgery using autologous (flaps) or heterologous materials aim to reduce surgical morbidity by making-up for the loss of substance to restore the function. The impact of these substantial changes in surgical techniques has not been assessed with respect to postoperative radiotherapy practice. Endoscopic endonasal approaches result, however, in piecemeal resection, which, along the analysis of resection margins (a key prognostic factor), make the interpretation of the quality of resection more complex for radiation oncologists. The definition of tumour sub-volumes to be irradiated and doses to these sub-volumes then requires accurate histosurgical mapping and close multidisciplinary consultation between surgeons, pathologists, radiologists and radiation oncologists. Similarly, the increasing use of various types of flaps (of soft tissue or bone flaps), adapted to the patient and tumor anatomy, is associated with substantial modifications to the operating bed. The delineation of tumour volumes in postoperative radiotherapy is made more complex. Tremendous multidisciplinary efforts should now be initiated to fully take advantage of surgical advances and to further optimize the therapeutic index by making radiotherapy also less toxic, i.e. "mini-morbid".
在法国，微创手术和重建手术往往成为头颈部肿瘤治疗的标准方法。采用内镜入路（通过鼻内镜/经口入路±机器人辅助）而非开放手术，以及使用自体（皮瓣）或异体材料进行重建手术，旨在通过弥补组织缺失来恢复功能，从而降低手术并发症。然而，这些手术技术的重大变革对术后放疗实践的影响尚未得到评估。不过，鼻内镜入路会导致肿瘤的分块切除，这与切缘分析（一个关键的预后因素）一起，使得放射肿瘤学家对切除质量的解读更加复杂。确定需要照射的肿瘤亚体积及其剂量，需要精确的组织手术图谱以及外科医生、病理学家、放射科医生和放射肿瘤学家之间密切的多学科会诊。同样，越来越多地使用各种类型的皮瓣（软组织或骨瓣），根据患者和肿瘤的解剖结构进行调整，这也会使手术床发生重大改变。术后放疗中肿瘤体积的勾画变得更加复杂。现在应该发起巨大的多学科努力，以充分利用手术进展，并通过使放疗毒性更小，即“微创伤”，来进一步优化治疗指数。
