H&N Preceptorship: focus oncomprehensive management15-17 October 2014 - Nice, France

FINAL PROGRAMME AND ABSTRACT BOOK

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Rachel ClarkCEO, EXCEMED

Dear participant,

A warm welcome to all attending the course “H&N Preceptorship: focus on comprehensive management”.

I would like to inform you that as of 28 April 2014 the name of our Foundation changed to EXCEMED - Excellence inMedical Education. The name change will not impact your registration status in this or any other Foundation event.

This transition marks an exciting point in the evolution of the Foundation. We are proud to have provided world-classeducation to thousands of healthcare professionals over the past four decades - as a result, the Foundation has becomesynonymous with delivery excellence and high-impact CME.

As we further develop our scientific and geographical presence it is important to us that our name accurately reflectsthe independent nature of the education we provide; EXCEMED symbolises our enduring mission to support the bestpossible outcomes for patients through the medical education we offer. We take pride in our complete dedication to theprovision of CME - it is our sole focus and our passion.

I wish you an inspiring and successful learning experience here in Nice.

Yours sincerely,

General information

VenueThis live educational course takes place at the:Institut Universitaire de la Face et du CouCentre Antoine Lacassagne (CAL) 33, Avenue de ValombroseNice, France

LanguageThe official language of this live educational course is English.

Scientific secretariatEXCEMED - Excellence in Medical EducationSalita di San Nicola da Tolentino, 1/b00187 Rome, Italy

Associate Programme Manager: Francesca CucciollaT: +39 06 420413 315F: +39 06 420413 677E-mail: info@excemed.org

Medical Advisor: Cristina Raimondi

EXCEMED is a Swiss Foundation with headquarters in 14, Rue du Rhône, 1204 Geneva, Switzerland

Organising secretariatMeridiano Congress InternationalVia Sapri, 6 - 00185 Rome, ItalyCongress Coordinator: Denise LatinoT +39 06 88 595 213 - F +39 06 88595 234 E-mail: d.latino@meridiano.it

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H&N Preceptorship: focus on comprehensivemanagement

EXCEMED live educational course:

H&N Preceptorship: focus on comprehensive management15-17 October 2014 - Nice, France

AimsThe landscape of treatment options for head and neck cancer patients has expanded considerably in the recent years and combinedmodality programmes have become the standard of care. Advances in radiotherapy treatment planning and delivery as well as insurgical techniques, and the introduction of molecular targeted agents into clinical practice led to a significant improvement inpatient outcomes. This activity will offer the opportunity to review current treatment options for head and neck cancer and tohighlight areas of new knowledge and controversy in the multidisciplinary management of head and neck cancer patients. Effectiveinteraction between the multidisciplinary team and participants will be encouraged through clinical case discussions and practicalsessions dedicated to treatment planning and delivery.

Learning objectivesAfter attending this live educational course, participant will be able to:• Define the methodology of the multidisciplinary approach in the management of head and neck cancer patients• Summarise and apply current combined modality programmes for the treatment of head and neck cancer patients• Discuss the integration of new diagnostic and therapeutic technologies in the clinical management of head and neck cancerpatients

Target audienceInternational medical oncologists, surgeons and radiation oncologists experienced in the management of head and neck cancerpatients.

AccreditationEXCEMED (www.excemed.org) is accredited by the European Accreditation Council for Continuing Medical Education (EACCME®) toprovide the following CME activity for medical specialists. The EACCME® is an institution of the European Union of MedicalSpecialists (UEMS), www.uems.net

The CME course “H&N Preceptorship: focus on comprehensive management” held on 15-17 October 2014 in Nice, France, isdesignated for a maximum of 13 (thirteen) hours of European CME credits (ECMEC). Each medical specialist should claim onlythose credits that he/she actually spent in the educational activity. EACCME® credits are recognized by the American MedicalAssociation (AMA) towards the Physician's Recognition Award (PRA). To convert EACCME® credit to AMA PRA category 1 credit,please contact the AMA.

EXCEMED adheres to the principles of the Good CME Practice Group (gCMEp)

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Scientific organiser

Frederic Peyrade Medical OncologyCentre Antoine Lacassagne (CAL)Institut Universitaire de la Face et du CouNice, France

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Faculty members

Karen BenezeryRadiotherapy OncologyCentre Antoine Lacassagne (CAL)Institut Universitaire de la Face et du CouNice, France

Emmanuelle BesrestCentralised unit of chemotherapy preparation (CUCP)Centre Antoine Lacassagne (CAL)Institut Universitaire de la Face et du CouNice, France

Alexandre BozecSurgery OncologyCentre Antoine Lacassagne (CAL)Institut Universitaire de la Face et du CouNice, France

Olivier DassonvilleSurgery OncologyCentre Antoine Lacassagne (CAL)Institut Universitaire de la Face et du CouNice, France

Axel LeysalleRadiotherapy OncologyCentre Antoine Lacassagne (CAL)Institut Universitaire de la Face et du CouNice, France

Share your opinion with usWe are always looking for ways to bring our educational activities to the next level and meet your needs as a healthcarepractitioner.

You will be asked to answer a post-event online survey after this event to find out if the experience met your educationalexpectations. Your views also help us tailor future initiatives.

Thank you for taking the time to participate.

Frederic PeyradeMedical OncologyCentre Antoine Lacassagne (CAL)Institut Universitaire de la Face et du CouNice, France

Gilles PoissonnetSurgery OncologyCentre Antoine Lacassagne (CAL)Institut Universitaire de la Face et du CouNice, France

Esma SaadaMedical OncologyCentre Antoine Lacassagne (CAL)Institut Universitaire de la Face et du CouNice, France

Anne SudakaBiopathologyCentre Antoine Lacassagne (CAL)Institut Universitaire de la Face et du CouNice, France

Scientificprogramme

Scientific programme

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Chair: F. Peyrade (France)

14.00 L1: Epidemiology and current approaches in surgical management of HNCA. Bozec (France)

14.20 L2: Current approaches in radiotherapymanagement of HNCK. Benezery (France)

14.40 L3: Current approaches in chemotherapymanagement of HNCF. Peyrade (France)

15.00 L4: Synthesis: benefits of the multidisciplinaryapproachF. Peyrade (France)

15.20 Coffee break

Global management of head and neck cancers Session I

Chair: F. Peyrade (France)

15.40 L5: BiopathologyA. Sudaka (France)

16.00 L6: Biopathology of head and neck tumorA. Sudaka (France)

16.20 L7: Physiopathology of head and neck tumorA. Sudaka (France)

16.40 L8: Impact of HPV in head and neck tumorA. Sudaka (France)

17.00 L9: Future developmentsA. Sudaka (France)

17.20 PS1: Biopathology laboratory and Tumor Bank presentation and visitA. Sudaka (France)

18.30 End of first day

Biopathology Session II

Practice session Session III

Legend: L : Lecture; PS : Practice Sessions; CS : Clinical cases discussion

Wednesday, 15 October 2014

13.00 Welcome lunch

13.45 Welcome and introductionF. Peyrade (France)

Thursday, 16 October 2014

Chair: O. Dassonville (France)

09.00 Welcome coffee

09.30 L10: General principles of surgical management inHNC patientsO. Dassonville (France)

09.50 L11: Surgical management of cervical nodesG. Poissonnet (France)

10.10 L12: State of reconstructive surgeryG. Poissonnet (France)

10.30 Coffee break

11.00 L13: HN surgeon in the future: sentinal nodes, torsand reconstructionA. Bozec (France)

11.20*CS1: Clinical cases in real and technicalprocedures (video session)O. Dassonville (France)

12.30 Lunch

Chair: K. Benezery (France)

14.00 L14: The role of the radiotherapist: treatment planning and delivery in the setting of head and neck radiotherapyA. Leysalle (France)

14.30 L15: New techniques in radiation therapy for head and neck cancer K. Benezery (France)

15.00 L16: Local and systemic toxicities in patienttreated with radiotherapy for head and neckcancerA. Leysalle (France)

15.30 L17: Open clinical trials at the CAL Center K. Benezery (France)

16.00 Coffee break

SurgerySession IV

Radiotherapy ** Session V

16.15 Transfer to the Protontherapy center

16.35 Visit at Prontotherapy centerA. Leysalle (France)

17.00 PS2: Demonstration on S2C2 Cyberknife - roboticradiosurgery systemA. Leysalle (France)

18.00 End of the second day and transfer back tothe Centre Antoine Lacassagne (CAL)

Practice session Session VI

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** Medical oncologists and radiotherapists who attend the meeting will be offered the possibility to participate in practice sessions otherthan the surgery videosession, according to their specific expertise and to the hospital schedule.

** Surgeons can choose between activities proposed in the programme and activities in the surgery room, according to the weeklyschedule of operations.

Scientific programme

Friday, 17 October 2014

Chair: E. Saada (France)

09.00 Welcome coffee

09.30 L18: Induction chemotherapyF. Peyrade (France)

10.00 L19: Metastatic and palliative chemotherapyE. Saada (France)

10.30 L20: Palliative treatmentsE. Saada (France) and F. Peyrade (France)

11.00 PS3: Visit at Centralised unit of chemotherapypreparation E. Besrest (France)

11.45 PS4: Clinical research unit visitE. Besrest (France)

12.30 Lunch

14.00 CS2: Clinical cases discussion***All faculty members

15.30 Conclusion and synthesisAll faculty members

15.45 End of the live educational preceptorshipcourse

Global management in the real lifeSession IX

Medical oncologySession VII

Practice session Session VIII

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*** Participants are invited to send a clinical case concerning controversies in the management of head and neck cancer patients. The three most exemplificative clinical cases (one on surgery, one on radiotherapy and one on medical oncology) will be selected bythe faculty and discussed during the meeting.

Disclosure of faculty relationships

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EXCEMED adheres to guidelines of the European Accreditation Council for Continuing Medical Education (EACCME®) and all otherprofessional organizations, as applicable, which state that programmes awarding continuing education credits must be balanced,independent, objective, and scientifically rigorous. Investigative and other uses for pharmaceutical agents, medical devices, and otherproducts (other than those uses indicated in approved product labeling/package insert for the product) may be presented in theprogramme (which may reflect clinical experience, the professional literature or other clinical sources known to the presenter). We askall presenters to provide participants with information about relationships with pharmaceutical or medical equipment companies thatmay have relevance to their lectures. This policy is not intended to exclude faculty who have relationships with such companies; it isonly intended to inform participants of any potential conflicts so that participants may form their own judgements, based on fulldisclosure of the facts. Further, all opinions and recommendations presented during the programme and all programme-relatedmaterials neither imply an endorsement nor a recommendation on the part of EXCEMED. All presentations represent solely theindependent views of the presenters/authors.

The following faculty provided information regarding significant commercial relationships and/or discussions of investigational ornon-EMEA/FDA approved (off-label) uses of drugs:

Alexandre Bozec Declared no potential conflict of interest.

Olivier Dassonville Declared no potential conflict of interest.

Axel Leysalle Declared no potential conflict of interest.

Gilles Poissonnet Declared no potential conflict of interest.

Esma Saada Declared no potential conflict of interest.

The following faculty have provided no information regarding significant relationship with commercial supporters and/or discussionof investigational or non-EMEA/FDA approved (off-label) uses of drugs as of 7 October 2014.

Karen Benezery

Emmanuelle Besrest

Frederic Peyrade

Anne Sudaka

Abstracts

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L1. Epidemiology and current approaches in surgicalmanagement of HNC

The objectives of this presentation are to discuss the changes in the epidemiology of head and neck squamous cell carcinoma(HNSCC) and the current role of surgery in the multimodal management of HNSCC patients.

HNSCC is the sixth most common cancer worldwide. In France, HNSCC is the fourth and the ninth most common cancer in menand women, respectively. Between 1980 and 2010, the world-standardised incidence rates of HNSCC decreased in men butincreased in women. Alcohol drinking and tobacco smoking are the two main risk factors. These two exposures may explain up to75% of all HNSCC cases. However, this rate is decreasing in Western countries. Diet, HPV infection, low socioeconomic status, andgenetic susceptibility have all been indicated as other potential risk factors. While rates of laryngeal, oral, and hypopharyngealsquamous cell carcinoma have been decreasing, the incidence of oropharyngeal squamous cell carcinoma has been rising. Therehas also been a change in the patient demographic from a population of older patients with a strong history of tobacco and alcoholuse to a younger population of patients with a limited history of tobacco and alcohol use.

In spite of the increasing incidence of oropharyngeal cancer, overall survival has been improving. Evidence suggests that theincreased incidence, changing demographics, and improved survival characteristic of oropharyngeal cancer were associated withHPV infection.

Surgery is the most well established mode of initial definitive treatment for a majority of oral cancers. The role of surgery in primarysquamous cell carcinomas in other sites in the head and neck has evolved with integration of multi-disciplinary treatmentapproaches employing chemotherapy and radiotherapy either sequentially or concurrently. Thus, larynx preservation withconcurrent chemoradiotherapy or with induction chemotherapy followed by radiotherapy has become the standard of care for locallyadvanced carcinomas of the larynx or hypopharynx requiring total laryngectomy. However, this surgery is still indicated as primarytreatment in patients with locally advanced larynx or hypopharynx cancer with cartilage invasion and extralaryngeal extension or assalvage procedure in patients with local recurrence after chemoradiotherapy.

On the other hand, for early staged tumours of the larynx and pharynx, transoral laser microsurgery has become an effective meansof local control of these lesions. Furthermore, in selected cases, open partial (pharyngo)-laryngectomy is still recognised as aneffective method of functional preservation and is associated with high local tumour control rates.

The role of surgery in oropharyngeal cancer is controversial. There are no prospective randomised studies comparing primarysurgery followed by postoperative chemo- or radiotherapy with definitive concurrent chemoradiotherapy. The advances in surgicaltechniques, including transoral surgery and microvascular reconstruction, have considerably improved functional outcomes oforopharyngeal cancer surgery.

Finally, the surgeon has an essential role throughout the life history of a patient with a malignant neoplasm in the head and neckarea, from initial diagnosis through definitive treatment, post-treatment surveillance, management of complications, rehabilitationof the sequelae of treatment, and finally for palliation of symptoms.

Alexandre BozecSurgery Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L2. Current approaches in radiotherapy management ofHNC

Radiotherapy is an integral component of the current multimodality treatment approach in head and neck cancer (HNC). In earlystage (I–II) disease, either conservative surgery or radiotherapy (external radiotherapy or brachytherapy) gives similar locoregionalcontrol. However, this is based only on retrospective studies as there are no randomised trials available for reference. Standardoptions for locally advanced stage III and IV tumours are: surgery including reconstruction plus postoperative radiotherapy and, forthose patients found at surgery to have high-risk features, post-operative chemoradiotherapy (CRT) with single-agent platinum tominimise the chance of microscopic disease left after treatment. However, in resectable patients, when the anticipated functionaloutcome and/or the prognosis is so poor that mutilating surgery is not justified, combined concomitant chemoradiation is preferred.Combined concomitant chemoradiation is also the standard treatment in nonresectable patients. More recently, epidermal growthfactor receptor (EGFr) molecular targeting with cetuximab combined with radiotherapy has been successfully tested in a largerandomised trial and this combination constitutes a new option, especially for patients with medical co-morbidities.

The role of induction chemotherapy (ICT) followed by RT-CT (so-called sequential CT-RT) is still under evaluation, and is notconsidered standard treatment in advanced disease but an option for organ preservation in advanced larynx and hypopharynx cancerin patients otherwise requiring total laryngectomy. In addition, RT may be used palliatively when disease is incurable. In selectedcases of localised recurrence, surgery (if operable) and/or re-irradiation can be considered.

Finally, management of treatment related acute or late toxicity remains an important issue and in the last decade majorachievements have been obtained in this field, especially using intensity modulated radiotherapy (IMRT).

Karen BenezeryRadiotherapy Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L3 & L4. Current approaches in chemotherapymanagement of HNC and the benefits of themultidisciplinary approach

Head and neck cancer (HNC) remains the sixth most frequent cause of death by cancer worldwide. Management of the disease isbased on a multidisciplinary approach combining surgery, radiotherapy, chemotherapy with other wide-ranging specialties,including reconstructive plastic surgery, nutrition and dermatology. Multimodal treatment is the best way to achieve improvedfunction, quality of life and survival, and it requires excellent coordination between the physicians involved in treatment.

The gold standard for unresectable, locally advanced squamous cell HNC is the association of radiotherapy plus cisplatinum-basedchemotherapy (RT-CT). Recently, biologic therapy has been employed in various combinations in an attempt to eradicate bothclinically apparent and occult disease. The combination of biologic therapy (cetuximab) plus radiotherapy (RT-Cet) has beendemonstrated to be superior to radiotherapy alone in a randomised phase III study. No direct comparison between RT-CT and RT-Cet is available.

Frederic PeyradeMedical Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L5, L6, L7, L8 & L9. Biopathology and physiopathology ofhead and neck tumours

Anatomo-histopathologic analysis is an important feature, alongside clinical tumour, nodes, metastasis (TNM) staging, in themanagement of head and neck cancer. Histologic diagnosis of biopsy tissue is the only examination enabling legal commencementof treatment, whether surgery and or radiation/chemotherapy.

At the peri-operative stage, the aim of the extemporaneous examination is to guide, and even modify, the surgical procedure,particularly by means of analysis of the surgical margins.

Post-operatively, the final analysis of the operative piece is recorded in a standardised report containing information which enablesthe clinician to decide whether or not to undertake adjuvant treatment and/or suggest inclusion in a clinical trial.

Anatomo-histopathology is a constantly evolving specialty which must adapt quickly to surgical advances and to variations in theepidemiologic profiles of head and neck cancers. Notably, with the increase in HPV-induced cancers and the growing power oftargeted therapies, the specialty has become “the Biopathology”.

In addition to possessing diagnostic expertise, the biopathologist has responsibility for the “tissue”, guaranteeing the quality of itspre-analysis and also of its conservation in tumour depositories, which are designed to facilitate research and/or to validate newbiomarkers for predicting the efficiency of novel treatment molecules.

Anne SudakaBiopathology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L10. General principles of surgical management in HNCpatients

Surgical procedures in head and neck cancers (HNC) must comply with the common rules of oncological surgery. The complexanatomy and multiple and varied physiological functions of the superior aerodigestive tract make this a particularly difficultrealisation.

The main rules for this type of surgery are:

01. The process must be agreed in a multi-disciplinary meeting and balanced with other therapeutic alternatives

02. Safe and reliable techniques must be used, with low mortality and morbidity rates and which ensure reasonable irradiation times

03. The surgery must be complete with clear, pre-defined surgical margins

04. The procedure must allow for extemporaneous histological analysis at both superficial and deep excision limits

05. Usually, lymph node surgery will need to be combined with the excision of the primary tumour (neck dissection, sentinal nodes)

06.Monobloc surgery is mandatory for an unfragmented primary tumour

07. The surgical specimen must be oriented and marked for histopathological analysis, and explanatory figures and pictures arestrongly advised

08. Reconstructive surgery is often required at the same time of excision to restore function and optimise quality of life

09. The surgical report must be accurate and focused on high-risk areas of the residual tumour

10. Surgical and histopathological reports must be discussed by the multi-disciplinary team and a plan drawn up for postoperativetherapeutic care

Olivier DassonvilleSurgery Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L11. Surgical management of cervical nodes

Head and neck squamous cell carcinoma (HNSCC) frequently spreads across the cervical lymph nodes. The presence of regionalmetastases is critical for staging, treatment and prognosis. The involvement of cervical lymph nodes can decrease disease-specificsurvival by up to 50%. The risk of positive nodes increases according to the tumour site, from 20% with oral cavity tumours to 75%for tumours of the hypopharynx.

Surgical treatment is dependent on staging by the six levels of standardised classification of the American Academy ofOtolaryngology Head and Neck Surgery, 1991. The neck dissection is well defined according to anatomic spots and lymph nodegroups. The preservation or not of nonlymphatic structures is based on radical neck dissection, which is considered to be thestandard basic procedure. However, modified and various selective neck dissections allow better functional outcome.

Positive clinical necks need adapted neck dissection with the removal of the primary tumour. Related to N0 necks, because of thehigh risk of occult regional metastasis, patients surgically treated for head and neck carcinoma require elective neck dissectionswhen the tumour size and subsite confer a risk of lymphatic spread of up to 15%. According to the concept of minimal invasivesurgery, sentinel lymph node biopsy can be performed in patients with early oral cavity carcinoma clinical N0 neck.

Focusing on current trends and on the experience of our Institution, we discuss the management of cervical lymph nodes based onclinical cases.

Gilles PoissonnetSurgery Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L12. State of reconstructive surgery

The outcome of surgery for head and neck cancers depends on two main considerations: firstly the risk of cervical complicationssuch as cervical fistulae within the oropharyngeal cavity which increases the risk of sepsis and bleeding, and secondly the functionaloutcomes in terms of swallowing and phonation which have a significant impact on patients’ quality of life.

Reconstructive surgery is an essential part of the surgical procedure and requires substantial knowledge of pedicled andmicrovascular free flaps to fully exploit all the potential reconstructive possibilities.

Based on the clinical experience in our Institution, the indications and various operative techniques will be discussed, illustrated withclinical cases. The aim of the presentation is to describe the standard approaches according to the typical failures and difficultieswhich occur during flap surgery. The focus will then move on to current standard procedures which represent the best combinationof safety, simplicity and reliability with functional outcomes.

Gilles PoissonnetSurgery Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L13. HN surgeon in the future: sentinal nodes, tors andreconstruction

The objective of this presentation is to discuss the role of the head and neck surgeon in the future. The management of head andneck cancer and particularly of head and neck squamous cell carcinoma (HNSCC) is continuously evolving. Treatment of patientswith HNSCC requires a multi-disciplinary approach including surgery, radiotherapy, chemotherapy and supportive care. Therapeuticprotocols become more and more complex and the role of sequential and / or concurrent chemoradiotherapy in the initialmanagement of HNSCC patients is expanding. However, the head and neck surgeon retains a pivotal role in the global managementof HNSCC patients, including initial diagnosis and staging, treatment selection, multimodal treatment, surveillance and, if needed,salvage therapy.

Considerable advances have been accomplished in surgical techniques, including minimal / less invasive oncologic surgery andmicrovascular reconstruction. The advances in procedures have led to a significant reduction of functional and aestheticimpairments associated with head and neck cancer surgery. Transoral laser or robot-assisted surgery (TORS) has substantiallyimproved early postoperative outcomes and functional results in early stage oropharyngeal, glottic or supraglottic surgical cancertreatment. In patients with early stage oral or oropharyngeal cancer, sentinel lymph node biopsy is a minimally-invasive and highlyreliable staging method for the clinically N0 neck and has become the standard of care in many centres throughout the world. Thistechnique could reduce the rate of complications and morbidity associated with elective neck dissection without reduction inlocoregional control and survival.

In locally advanced head and neck tumours, significant advances have been accomplished by the refinement of surgical techniquessuch as lip-sparing and combined transoral and transcervical approaches without mandibulotomy. However, in such tumours, themost significant surgical progress has been provided by the improvement of reconstructive techniques, in particular the advent ofmicrovascular free-flap reconstruction.

Alexandre BozecSurgery Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L14. The role of the radiotherapist: treatment planning anddelivery in the setting of head and neck radiotherapy

Radiotherapy is an integral part of primary or adjuvant treatment of squamous cell head and neck cancer (SCHNC). Advances inradiation therapy techniques and in chemotherapeutic agents have led to the widespread use of a multidisciplinary team approachfor treating these challenging tumours. Radiation therapy for treatment of SCHNC is typically given in daily fractions of 2·0 Gy, 5 daysa week, up to a total dose of 70 Gy over 7 weeks. Post-operatively, radiation doses of 60–66 Gy are usually prescribed; increasing thetotal dose to at least 63 Gy improves locoregional control when extracapsular extension is present.

A comprehensive assessment of the patient, including symptoms, compliance, nutritional status, and multi-modality imaging, is anessential process in order to maximise the result of treatment and limit the risk of treatment failure. Long-term interruptions toradiotherapy or delays in starting post-operative radiotherapy are potentially harmful, presumably because of repopulation of cancercells.

Advances in imaging and radiation delivery have dramatically changed management approaches. Planning CT scans are nowfrequently combined with diagnostic CT, MRI, or PET datasets to improve tumour delineation in three dimensions. Intensity-modulated radiation therapy (IMRT) represents an advanced form of radiation in three dimensions. A computer-controlled treatmentmachine is used to produce many radiotherapy beams in which the intensity is optimised to deliver a high dose of radiation tospecified volumes, while reducing the dose and, theoretically, the toxic effect on adjacent non-target tissues. IMRT uses inverseplanning to protect healthy tissue from chronic damage by limiting the dose delivered to sensitive areas such as the salivary tissue.Emerging institutional data suggest promising locoregional tumour control, as well as potential preservation of salivary function,swallowing, and overall quality of life with IMRT. In case of significant anatomical deformations associated with head and necktumours (tumour shrinkage and a decrease in volume of the salivary glands), replanning appears to be necessary, corresponding toadaptive radiotherapy.

Axel LeysalleRadiotherapy Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L15. New techniques in radiation therapy for head andneck cancer

In recent years, radiotherapy has benefited from advances in cancer imaging, treatment planning computer software anddevelopments in radiation delivery technology. It is now one of the most technology-driven branches of medicine. Typically head andneck cancer patients will have radiation therapy which is based on state of the art imaging technology including CT, MRI, PET orother imaging techniques. Radiation therapy has been mostly based on photons (and electrons) in the last 50 years. More recently,several institutions have been equipped with particle beam therapy equipment delivering protons or carbon ions.

New irradiation techniques have been developed through improvements in production technologies, including optimisation ofphoton-based facilities with linear accelerators (LINAC) for modulated arc therapy, or dedicated computed tomography (CT)-basedTomoTherapy (TOMO), stereotactic radiation therapy including Cyber-Knife–Novalis ExacTrac, and cyclotrons/synchrotrons. High-speed computer software allows sophisticated treatment planning (intensity-modulated techniques) and imaging with image-guidedradiation therapy (IGRT). The level of evidence is limited because of the lack of randomised studies comparing the old and newirradiation techniques, but the benefits of these innovative radiation techniques and equipment for clinical practice on tumourcontrol, survival, toxicity, and quality of life (QOL) endpoints will be discussed. We will also address the role of Contact X Ray therapy(CXRT), an early brachytherapy technique recently undergoing a renaissance.

Karen BenezeryRadiotherapy Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L16. Local and systemic toxicities in patient treated withradiotherapy for head and neck cancer

Meta-analyses of treatment regimens for head and neck cancer (HNC) have shown improved survival if radiation therapy andchemotherapy were combined compared to radiation therapy alone. On the other hand, combined radiation and chemotherapycauses severe short- and long-term toxicity. This becomes particularly evident in the head and neck region, a complex areacomposed of several dissimilar structures that respond differently to radiation: mucosal linings, skin coverings, subcutaneousconnective tissue, salivary gland tissue, teeth, and bone/cartilage.

Acute changes produced by radiotherapy are observed in the oral mucosa (erythema, pseudomembrane-covered ulceration),salivary glands (hyposalivation, changed salivary composition), taste buds (decreased acuity), and skin (erythema, desquamation).Late changes can occur in all tissues.

Although thorough protocols have been developed to minimise or manage the early and late oral sequelae of radiotherapy of thehead and neck region, the consequences of radiation-induced salivary gland injury and the other oral sequelae of head and neckradiotherapy are still difficult to manage. The planning process of radiotherapy limits toxicity. Planning CT scans are now frequentlycombined with diagnostic CT, MRI, or PET datasets to improve tumour delineation in three dimensions. Intensity-modulatedradiation therapy (IMRT) enables the delivery of increased doses to tumour tissue while limiting the dose delivered to normalstructures.

Axel LeysalleRadiotherapy Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L17. Open clinical trials at the CAL Center

Within the framework of current practice, clinical (radiotherapy) trials which are ongoing at CAL in Nice will be explained.

• ELAN ONCOVAL / Elderly Head and Neck Cancer study: Investigating personalised treatment according to geriatric assessment in patients age 70 or older First prospective trials in patients with squamous cell cancer of the head and neck (HNSCC) unsuitable for surgery

• ARTIX

Phase III trial in locally advanced oropharynx carcinoma aimed at decreasing xerostomia

Comparing the benefit of intensity-modulated radiotherapy with weekly replanifications versus intensity modulatedradiotherapy with only one planification

Karen BenezeryRadiotherapy Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L18. Induction chemotherapy

The standard treatment for head and neck inoperable squamous cell carcinoma is a combination of radiotherapy and platinum.However, only one patient out of three remains alive 5 years after diagnosis. The interest in induction chemotherapy has beenrenewed by the introduction of taxanes combined with cisplatinum and 5-fluoro-uracil (5-FU) (TPF). The triple combination yieldedimproved survival when compared to cisplatinum–5 FU.

However, wider use of TPF is limited by its toxicity and the lack of randomised studies comparing it with a concomitantchemoradiotherapy (CRT) scheme including optimal doses of platinum. Ghi et al. reported at ASCO 2014 that inductionchemotherapy followed by CRT is superior to conventional CRT in terms of overall survival, but these data remain to be confirmed.

Thus, the choice between induction chemotherapy followed by concomitant CRT or concomitant CRT alone has to be made on anindividualised basis, taking into account the patient’s medical condition, the ability of the medical team to deal with intensivetreatment regimens, and the clinical/pathological characteristics of the tumour.

Frederic PeyradeMedical Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L19. Metastatic and palliative chemotherapy

Worldwide, head and neck squamous cell carcinomas (HNSCC) account for 5% of all malignancies. Two-thirds of patients relapseafter initial multimodal therapy. Until early 2000, the median overall survival (OS) of recurrent/metastatic (RM) patients was about 6months. Recently, new drugs have been incorporated into patient management, thus enabling an increase in OS, although surgeryand/or radiotherapy remain the cornerstones of treatment for RM HNSCC.

In this setting, performance status (PS) assessment is the most important criterion for deciding on a treatment regimen. For PS 0-1 patients, the standard first-line treatment is six cycles of cisplatin-5-FU-cetuximab followed by cetuximab alone until progressionor unacceptable toxicity. For second-line treatment, the options are: enrolment in clinical trials, single-agent therapy (withmethotrexate, taxane, or cetuximab), or best supportive care (BSC). In all cases, supportive care must be initiated very early in thecourse of the disease, especially to prevent pain, dysphagia and malnutrition. Geriatric assessment could be helpful for elderlypatients; for first-line treatment of elderly RM-HNSCC patients, the therapeutic options are carboplatin, 5FU and cetuximab forthose patients in good general condition, and methotrexate alone or BSC for all other patients.

Esma SaadaMedical Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

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L20. Palliative treatments

Locally advanced and metastatic head and neck carcinoma are mostly treated in a palliative setting. Specific treatment goals are toincrease life expectancy and to optimise quality of life.

This lecture will review the several and complex disabilities and symptoms that are associated with head and neck tumourpathogenesis and treatments. Suggestions for therapeutic options for the most frequently-reported symptoms (physical imageimpairment, language impairment, dry mouth, bad smell, alcohol-related comorbidities, pain, cough and secretions, hemorrhagerisk, and poor psycho-social environment) will be considered. The cooperation of a multidisciplinary team of physicians, includingoncologists, radiotherapists, and surgeons, as well as palliative care teams (algologists, dieticians, psychologists, physiotherapists,nurses, sophrologists) is mandatory for success.

Esma SaadaMedical Oncology, Centre Antoine Lacassagne (CAL), Institut Universitaire de la Face et du Cou, Nice, France

NOTES

NOTES

All EXCEMED programmes are organized solely to promote the exchange and dissemination of scientific and medical information. No forms of promotional activitiesare permitted. There may be presentations discussing investigational uses of various products. These views are the responsibility of the named speakers, and donot represent an endorsement or recommendation on the part of EXCEMED. This programme is made possible thanks to an educational grant from Merck Serono.

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