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Keynote Address III
S2
J. Bernier / Oral Oncology 49 (2013) S1–S3
There is probably improved oral cancer health awareness among affluent populations, but only minor improvements among low socio-economic cultural classes and ethnic groups and this subsequently increases longstanding inequalities in healthcare – a paradoxical effect known as the Inverse Care Law (Hart JT. The inverse care law. Lancet 1971; 297:405–12). Any oral cancer preventable effects of modalities such as anti-HPV vaccination, and cost-effectiveness, are unknown. The main task therefore, appears to be to endeavour to get Public Health measures used more by individuals who need them most (Victora CG, Vaughan JP, Barros FC, Silva AC, Tomasi E. Explaining trends in inequities: evidence from Brazilian child health studies. Lancet 2000;356:1093–8.). This is a large challenge, not least since we can no longer stereotype those affected by oral cancer as the traditional risk groups of older males who use tobacco and alcohol. Acknowledgement: Thanks to Professors S Petti, P Speight, & S Warnakulasuriya for comments. doi:10.1016/j.oraloncology.2013.03.462
Keynote Address III The reconstruction of the face of a 2500 year-old girl: Myrtis Manolis J. Papagrigorakis In 1944–1945, during works for the construction of the new Athens Metro in the historical area of the ancient cemetery of Athens, Keramikos, the archaeological excavation brought to light a common grave, which dates back to the time of the notorious Plague of Athens (430–426 B.C.) that killed Pericles and decimated the Athenians. The grave contained skeletal remains of ca. 150 people, both children and adults, and among them the skull of an eleven year-old girl, which retained both deciduous and permanent teeth, a characteristic typical for her age. The child – who was given the ancient name Myrtis – died of typhoid fever during the plague of Athens. Typhoid fever is even today – after 2500 years – the cause of death for 500.000–700.000 people every year. Moreover, each year nearly nine million children under five are losing their lives from typhoid fever and other diseases that can be prevented and treated. For this reason, the United Nations Regional Information Centre (UNRIC) ‘‘asked’’ Myrtis to become a friend of the UN Millennium Development Goals and join, in her own unique way, the United Nations world campaign ‘‘We can End Poverty’’. After detecting the causative factor of her death, there occurred the idea of remolding the head and face of the ancient child. Although modern standards of ideal proportions and facial esthetics are based mostly on observations of human faces as depicted in Classical Greek masterpieces of art, the real faces of ordinary ancient Greeks have, until now, remained elusive and subject to the imagination. Objective forensic techniques of facial reconstruction have never been applied before, because human skeletal material from Classical Greece has been extremely scarce, since most decent burials of that time required cremation. The original skull was replicated via threedimensional modeling and rapid prototyping techniques. The reconstruction followed the Manchester method, laying the facial tissues from the surface of the skull outward by using depth marker pegs as thickness guides. The shape, size, and position of the eyes, ears, nose, and mouth were determined according to features of the underlying skeletal tissues, whereas the hairstyle followed the fashion of the time. This is the first case of facial reconstruction of a layperson residing in Athens of the Golden Age of Pericles. It is ironic, however, that this unfortunate girl who lived such a short life in ancient Athens, will now, 2500 years later, have the chance to travel
and be universally recognizable in a world much bigger than anybody in ancient Athens could have ever imagined. doi:10.1016/j.oraloncology.2013.03.463
Keynote Address IV Radiotherapy of head-and-neck cancer: From translational research to clinical optimization Jacques Bernier Genolier Swiss Medical Network and University of Geneva, Geneva, Switzerland Nowadays, managing head-and-neck cancer encompasses complex, multi-modality approaches, articulated around three main therapeutic pillars, namely surgery, radiotherapy and systemic treatments. Since the first applications of radiotherapy, in the 1920s at the Curie Institute, to patients with laryngeal tumors, head-and-neck cancer irradiation has been characterized by constant advances in terms of both technological and strategic breakthroughs. Under the impulsion of G.H. Fletcher in Houston, the combination of surgery and radiotherapy was the first real ‘‘concerted action’’ implemented in patients presenting with locally advanced disease, paving the way for both pre-operative and adjuvant strategies. About twenty years after the advent of high-energy beams, the refinement of irradiation techniques, essentially through the progressive shift from 2D- to 3D-conformal treatment planning and delivery, led the radio-oncology community to investigate the role of intensified schedules of irradiation, as definitive approach in patients with stage III–IV disease. In the early 1980s, EORTC successfully pioneered the use of hyperfractionated and accelerated regimes, followed by the implementation of very strong acceleration such as CHART in United Kingdom. Increasing cell killing and/or counterbalancing the tumor repopulation rates without affecting significantly the impact of irradiation on normal tissues were the declared objectives of the so-called ‘‘alteration of fractionation’’, objectives which were met in a significant number of both institutional and cooperative trials. The combination of cytotoxic drugs and radiotherapy was the next field of investigation, launched about 25 years ago, first through a phase of ‘‘learning curve’’ characterized by a significant acute morbidity, and thereafter by the level I of evidence reached in adjuvant setting with the results of EORTC and RTOG trial comparing the co-administration of radiation and cisplatin with postoperative radiotherapy alone. The concept of hitting concurrently various therapeutic targets was actually reinforced by these results, and the era of bio-radiation, based on targeted therapies combined to radiation, could begin. At the turn of the century, the progressive introduction of intensity-modulated radiation therapy (IMRT) met a number of requirements to increase the therapeutic ratio of irradiation-based strategies, especially as regards a significant sparing of radiosensitive structures like salivary glands, larynx, and skull base. Undoubtedly these highly conformal approaches nowadays represent an inflexion point for the role of radiotherapy in head-and-neck oncology, also in terms of quality of life for these patients. This Lecture will revisit these achievements and propose a critical appraisal of the complex management of this complex disease, without forgetting what could be, in the future, the parameters of choice to integrate even more successfully this discipline into strategies better tailored to clinical and biological features and risk levels. doi:10.1016/j.oraloncology.2013.03.464
J. Bernier / Oral Oncology 49 (2013) S1–S3
There is probably improved oral cancer health awareness among affluent populations, but only minor improvements among low socio-economic cultural classes and ethnic groups and this subsequently increases longstanding inequalities in healthcare – a paradoxical effect known as the Inverse Care Law (Hart JT. The inverse care law. Lancet 1971; 297:405–12). Any oral cancer preventable effects of modalities such as anti-HPV vaccination, and cost-effectiveness, are unknown. The main task therefore, appears to be to endeavour to get Public Health measures used more by individuals who need them most (Victora CG, Vaughan JP, Barros FC, Silva AC, Tomasi E. Explaining trends in inequities: evidence from Brazilian child health studies. Lancet 2000;356:1093–8.). This is a large challenge, not least since we can no longer stereotype those affected by oral cancer as the traditional risk groups of older males who use tobacco and alcohol. Acknowledgement: Thanks to Professors S Petti, P Speight, & S Warnakulasuriya for comments. doi:10.1016/j.oraloncology.2013.03.462
Keynote Address III The reconstruction of the face of a 2500 year-old girl: Myrtis Manolis J. Papagrigorakis In 1944–1945, during works for the construction of the new Athens Metro in the historical area of the ancient cemetery of Athens, Keramikos, the archaeological excavation brought to light a common grave, which dates back to the time of the notorious Plague of Athens (430–426 B.C.) that killed Pericles and decimated the Athenians. The grave contained skeletal remains of ca. 150 people, both children and adults, and among them the skull of an eleven year-old girl, which retained both deciduous and permanent teeth, a characteristic typical for her age. The child – who was given the ancient name Myrtis – died of typhoid fever during the plague of Athens. Typhoid fever is even today – after 2500 years – the cause of death for 500.000–700.000 people every year. Moreover, each year nearly nine million children under five are losing their lives from typhoid fever and other diseases that can be prevented and treated. For this reason, the United Nations Regional Information Centre (UNRIC) ‘‘asked’’ Myrtis to become a friend of the UN Millennium Development Goals and join, in her own unique way, the United Nations world campaign ‘‘We can End Poverty’’. After detecting the causative factor of her death, there occurred the idea of remolding the head and face of the ancient child. Although modern standards of ideal proportions and facial esthetics are based mostly on observations of human faces as depicted in Classical Greek masterpieces of art, the real faces of ordinary ancient Greeks have, until now, remained elusive and subject to the imagination. Objective forensic techniques of facial reconstruction have never been applied before, because human skeletal material from Classical Greece has been extremely scarce, since most decent burials of that time required cremation. The original skull was replicated via threedimensional modeling and rapid prototyping techniques. The reconstruction followed the Manchester method, laying the facial tissues from the surface of the skull outward by using depth marker pegs as thickness guides. The shape, size, and position of the eyes, ears, nose, and mouth were determined according to features of the underlying skeletal tissues, whereas the hairstyle followed the fashion of the time. This is the first case of facial reconstruction of a layperson residing in Athens of the Golden Age of Pericles. It is ironic, however, that this unfortunate girl who lived such a short life in ancient Athens, will now, 2500 years later, have the chance to travel
and be universally recognizable in a world much bigger than anybody in ancient Athens could have ever imagined. doi:10.1016/j.oraloncology.2013.03.463
Keynote Address IV Radiotherapy of head-and-neck cancer: From translational research to clinical optimization Jacques Bernier Genolier Swiss Medical Network and University of Geneva, Geneva, Switzerland Nowadays, managing head-and-neck cancer encompasses complex, multi-modality approaches, articulated around three main therapeutic pillars, namely surgery, radiotherapy and systemic treatments. Since the first applications of radiotherapy, in the 1920s at the Curie Institute, to patients with laryngeal tumors, head-and-neck cancer irradiation has been characterized by constant advances in terms of both technological and strategic breakthroughs. Under the impulsion of G.H. Fletcher in Houston, the combination of surgery and radiotherapy was the first real ‘‘concerted action’’ implemented in patients presenting with locally advanced disease, paving the way for both pre-operative and adjuvant strategies. About twenty years after the advent of high-energy beams, the refinement of irradiation techniques, essentially through the progressive shift from 2D- to 3D-conformal treatment planning and delivery, led the radio-oncology community to investigate the role of intensified schedules of irradiation, as definitive approach in patients with stage III–IV disease. In the early 1980s, EORTC successfully pioneered the use of hyperfractionated and accelerated regimes, followed by the implementation of very strong acceleration such as CHART in United Kingdom. Increasing cell killing and/or counterbalancing the tumor repopulation rates without affecting significantly the impact of irradiation on normal tissues were the declared objectives of the so-called ‘‘alteration of fractionation’’, objectives which were met in a significant number of both institutional and cooperative trials. The combination of cytotoxic drugs and radiotherapy was the next field of investigation, launched about 25 years ago, first through a phase of ‘‘learning curve’’ characterized by a significant acute morbidity, and thereafter by the level I of evidence reached in adjuvant setting with the results of EORTC and RTOG trial comparing the co-administration of radiation and cisplatin with postoperative radiotherapy alone. The concept of hitting concurrently various therapeutic targets was actually reinforced by these results, and the era of bio-radiation, based on targeted therapies combined to radiation, could begin. At the turn of the century, the progressive introduction of intensity-modulated radiation therapy (IMRT) met a number of requirements to increase the therapeutic ratio of irradiation-based strategies, especially as regards a significant sparing of radiosensitive structures like salivary glands, larynx, and skull base. Undoubtedly these highly conformal approaches nowadays represent an inflexion point for the role of radiotherapy in head-and-neck oncology, also in terms of quality of life for these patients. This Lecture will revisit these achievements and propose a critical appraisal of the complex management of this complex disease, without forgetting what could be, in the future, the parameters of choice to integrate even more successfully this discipline into strategies better tailored to clinical and biological features and risk levels. doi:10.1016/j.oraloncology.2013.03.464