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L'obtention du consentement aux soins impose à l'oncologue radiothérapeute la délivrance d'une information loyale et l'assurance de sa bonne compréhension par le patient. La preuve d'une telle démarche incombe au praticien. La Société française de radiothérapie oncologique (SFRO) ne recommande pas la signature par le patient d'un formulaire de consentement mais, recommande à l'oncologue radiothérapeute d'être en mesure de fournir tous les éléments démontrant la réalité d'un circuit d'information complet. Obtaining consent to care requires the radiation oncologist to provide loyal information and to ensure that the patient understands it. Proof of such an approach rests with the practitioner. The French Society for Radiation Oncology (SFRO) does not recommend the signature of a consent form by the patient but recommends that the radiation oncologist be able to provide all the elements demonstrating the reality of a complete information circuit. [ABSTRACT FROM AUTHOR]

Abstract: Bone marrow is one of the major dose-limiting tissue for radiotherapy. It is composed of many sub-units with complex regulatory mechanisms implying cytokines and growth factors, dispersed throughout the skeleton, each acting with a semi-autonomy but are unified into an integrated system that responds to ionizing radiations as one critical organ. A better knowledge of the complexity of this tissue''s distribution and physiology is fundamental to understanding and forecasting the consequences of radiation-induced bone marrow injury. According to cancer characteristics, the volume of hematopoietic bone marrow included within radiation fields and the dose it receives vary in a very significant way, and finally the impact on blood cell count varies in widely different ranges. Furthermore, to predict the overall risk of therapy-induced hematological toxicities, it is necessary to take into account the possible contemporary administration of other cytotoxic drugs (before and/or during radiation therapy). Conversely, the hematological toxicity of usually well-tolerated chemotherapies can be increased, if the patient has a history of radiotherapy. Although the importance of minimizing the volume of active bone marrow exposed to ionizing radiations is well established, so far, no consensual recommendation exists about the dose–volume relationship between bone marrow irradiation and hematological tolerance. Data have recently emerged from trials studying the interest of IMRT for treatment of pelvic malignancies which confirm that reducing bone marrow exposure to irradiation prevents the rise of hematological toxicities during and after radiation therapy, even if some questions remain unanswered on how to define the contours of bone marrow volume. [Copyright &y& Elsevier]

Abstract: The development of sophisticated conformal radiation therapy techniques for prostate cancer, such as intensity-modulated radiotherapy, implies precise and accurate targeting. Inter- and intrafraction prostate motion can be significant and should be characterized, unless the target volume may occasionally be missed. Indeed, bony landmark-based portal imaging does not provide the positional information for soft-tissue targets (prostate and seminal vesicles) or critical organs (rectum and bladder). In this article, we describe various prostate localization systems used before or during the fraction: rectal balloon, intraprostatic fiducials, ultrasound-based localization, integrated CT/linear accelerator system, megavoltage or kilovoltage cone-beam CT, Calypso 4D localization system tomotherapy, Cyberknife and Exactrac X-Ray 6D. The clinical benefit in using such prostate localization tools is not proven by randomized studies and the feasibility has just been established for some of these techniques. Nevertheless, these systems should improve local control by a more accurate delivery of an increased prescribed dose in a reduced planning target volume. [Copyright &y& Elsevier]

Les questions éthiques sont peu investiguées, particulièrement en oncologie radiothérapie. L'objectif de l'étude était d'expliciter la problématique éthique principale en oncologie radiothérapie. Une analyse quantitative a été basée sur la réponse à un questionnaire de 200 professionnels issus de 22 départements d'oncologie radiothérapie. Ce questionnaire visait principalement à caractériser le questionnement éthique principal. Une analyse qualitative monocentrique s'est appuyée sur des entretiens semi-dirigés centrés sur le questionnement éthique principal, réalisés avec huit manipulateurs d'électroradiologie et 20 patients en cours de radiothérapie. Le questionnement éthique principal était la compréhension et/ou l'acceptation du traitement par les patients (71 %), se posant fréquemment (plus d'une fois par mois) (52 %) et correspond à une tension éthique entre les principes de respect de l'autonomie et de bienfaisance (faire le bien tel que perçu par le patient) tels que définis par Beauchamp et Childress. Les manipulateurs d'électroradiologie souhaitent que le patient soit pleinement acteur de son traitement avec même la possibilité de le refuser. Excluant « paternalisme » et « acharnement autonomique », les manipulateurs d'électroradiologie ont cependant le sentiment d'agir pour le bien des patients en les traitant par irradiation, même si ceux-ci n'en sont pas toujours conscients parce qu'ils sont en situation de vulnérabilité. Si la hiérarchisation des principes est une alternative de compromis, cette problématique est finalement bien résolue par la mise en pratique effective d'une éthique de la considération et de la sollicitude, s'appuyant sur les « capabilités » du patient, visant l'épanouissement maximal de ses potentialités dans sa situation de vulnérabilité. Au-delà de la dimension juridique, l'information du patient est cruciale et doit prendre en compte la temporalité spécifique du patient. La question éthique principale en oncologie radiothérapie est celle de la compréhension et/ou l'acceptation du traitement impliquant le développement d'une éthique de la considération et de la sollicitude. Ethical questions are poorly investigated specifically in radiation oncology. The objective of the study was to identify and understand the main ethical issue in radiation oncology. A quantitative analysis was based on the answers to a questionnaire of 200 professionals from 22 radiation oncology departments. The questionnaire mainly aimed to characterize the main ethical issue. A monocentric qualitative analysis was based on semi-structured interviews focused on the main identified ethical issue, carried out with eight technologists, and 20 patients undergoing radiotherapy. The main ethical issue was the understanding and/or acceptance of the treatment by the patients (71 %), which frequently arises (more than once a month) (52 %), and corresponds to an ethical tension between the principles of respect for autonomy and beneficence (the good as viewed by the patient) as defined by Beauchamp and Childress. The technologists, wish the patient to be fully involved in his treatment, with the even possibility of refusing it. However, excluding paternalism and autonomic relentlessness, the technologists have the feeling of acting for the good of the patients by treating them with radiation, even if the patients are not always aware of it, because they are within a situation of vulnerability. If the hierarchy of principles is a compromise alternative, this problem is finally well resolved by the effective implementation of an ethic of consideration and solicitude, restoring the patient capabilities, i.e. the maximum development of his potentialities in his situation of vulnerability. Beyond the legal dimension, patient information is crucial and must consider the specific temporality of the patient. The main ethical issue in radiation oncology is the understanding and/or acceptance of the treatment involving the development of an ethic of consideration and solicitude. [ABSTRACT FROM AUTHOR]

Résumé Dix à 40 % des patients traités par prostatectomie totale sont atteints d’une rechute biochimique précoce ou tardive correspondant à une évolution locale ou à distance de la maladie. Le risque de récidive après prostatectomie totale dépend du stade initial, de l’analyse de la pièce opératoire et de la concentration sérique de l’antigène spécifique de la prostate (PSA) après la chirurgie. Trois essais randomisés ont montré qu’une irradiation adjuvante réduisait le risque de progression tumorale sans entraîner de toxicité majeure. La radiothérapie de rattrapage en cas de rechute biochimique tardive permet un contrôle dans 60 % à 70 % des cas. Plusieurs stratégies de recherche sont étudiées par le groupe d’étude des tumeurs urogénitales (Gétug) et l’Association française d’urologie (Afu) pour améliorer le ratio thérapeutique de la radiothérapie postopératoire. L’essai du Gétug et de l’Afu 17 discute du moment optimal de cette irradiation par la comparaison d’une radiothérapie adjuvante à une radiothérapie de rattrapage. L’essai du Gétug et de l’Afu 22 pose la question de la place d’une hormonothérapie courte associée à une radiothérapie conformationnelle avec modulation d’intensité pelvienne (RCMI) guidée par l’image en cas de PSA détectable immédiatement après la chirurgie. La mise en place d’un contrôle de qualité multicentrique au sein du Gétug et de l’Afu permettra le développement des prochains essais cliniques d’escalade de dose après la chirurgie. Between 10 and 40% of patients who have undergone a radical prostatectomy may have a biologic recurrence. Local or distant failure represents the possible patterns of relapse. Patients at high-risk for local relapse have extraprostatic disease, positive surgical margins or seminal vesicles infiltration or high Gleason score at pathology. Three phase-III randomized clinical trials have shown that, for these patients, adjuvant irradiation reduces the risk of tumoral progression without higher toxicity. Salvage radiotherapy for late relapse allows a disease control in 60–70% of the cases. Several research in order to improve the therapeutic ratio of the radiotherapy after prostatectomy are evaluate in the French Groupe d’Étude des Tumeurs Urogénitales (Gétug) and of the French association of urology (Afu). The Gétug-Afu 17 trial will provide answers to the question of the optimal moment for postoperative radiotherapy for pT3-4 R1 pN0 Nx patients, with the objective of comparing an immediate treatment to a differed early treatment initiated at biological recurrence. The Gétug-Afu 22 questions the place of a short hormonetherapy combined with image-guided, intensity-modulated radiotherapy (IMRT) in adjuvant situation for a detectable prostate specific antigen (PSA). The implementation of a multicenter quality control within the Gétug-Afu in order to harmonize a modern postoperative radiotherapy will allow the development of a dose escalation IMRT after surgery. [ABSTRACT FROM AUTHOR]

Abstract: The impact of curative radiotherapy depends mainly on the total dose delivered homogenously in the targeted volume. Nevertheless, the dose delivery is limited by the tolerated dose of the surrounding healthy tissues. Two different side effects (acute and late) can occur during and after radiotherapy. Of particular interest are the radiation-induced sequelae due to their irreversibility and the potential impact on daily quality of life. In a population treated in one center with the same technique, it appears that individual radiosensitivity clearly exists. In the hypothesis that genetic is involved in this area of research, lymphocytes seem to be the tissue of choice due to easy accessibility. Recently, low percentage of CD4 and CD8 lymphocyte apoptosis were shown to be correlated with high grade of sequelae. In addition, recent data suggest that patients with severe radiation-induced late side effects possess four or more SNP in candidate genes (ATM, SOD2, TGFB1, XRCC1 et XRCC3) and low radiation-induced CD8 lymphocyte apoptosis in vitro. [Copyright &y& Elsevier]

We present the update of the recommendations of the French society of oncological radiotherapy on bone metastases. This is a common treatment in the management of patients with cancer. It is a relatively simple treatment with proven efficacy in reducing pain or managing spinal cord compression. More complex treatments by stereotaxis can be proposed for oligometastatic patients or in case of reirradiation. In this context, increased vigilance should be given to the risks to the spinal cord. [ABSTRACT FROM AUTHOR]

En 2019, le bureau de la Société française de radiothérapie oncologique (SFRO) a créé une commission éthique. Sa mission est de proposer à notre communauté professionnelle des éléments de réflexion à propos de questionnements éthiques, et d'en dégager les spécificités au sein des services d'oncologie radiothérapie. À l'occasion du congrès annuel de 2020, la commission s'est penchée sur l'évolution de la relation soigné-soignant, et plus particulièrement sur l'idée forte de partenariat patient. En effet, la rédaction du Livre blanc du cancer a donné la parole aux personnes malades et souligné la nécessité de nouveaux dispositifs, tels que le « temps d'accompagnement soignant ». Les patients ne peuvent plus être considérés comme des objets de soin mais comme des personnes dont la dignité et l'autonomie doivent être impérativement respectées. L'acquisition de connaissances autorise un échange bilatéral, prérequis de la dynamique collaborative. Ils peuvent être partenaires de leurs propres soins, partenaires de la formation et de la recherche (patient expert) mais également partenaires des institutions et politiques de santé. C'est cette notion de partenariat et d'implication de la personne dans son parcours de soin en oncologie radiothérapie que nous allons analyser ici. Il s'agira autant de la définir, en développant la notion d'autonomie, que d'en faire émerger la complexité et l'ambivalence au travers notamment de deux exemples issus de notre pratique clinique : la démarche de décision partagée pour les patients ayant un cancer de la prostate localisé et l'implication du patient dans le bon déroulement de sa radiothérapie. In 2019, the scientific committee of the French society of radiation oncology (SFRO) created an ethics committee. Its mission is to provide our professional community with food for thought on ethical issues, and to identify its specificities within the radiation oncology departments. For the 2020 annual conference, the commission looked into the evolution of the patient-carer relationship, and more particularly to the strong idea of patient partnership. Indeed, the writing of the White Book of Cancer gave voice to sick people and stressed the need for new devices, such as the Caregiving Time. Patients can no longer be considered as objects of care but as people whose dignity and autonomy must be imperatively respected. The acquisition of knowledge allows a bilateral exchange, prerequisite of a dynamic collaboration. Patients can be partners in their own care, partners in training and research (expert patient), but also partners in health institutions and policies. It is this notion of partnership and involvement of the person in their path of care in radiation oncology that we will analyse here. It will be about defining it, by developing the concept of autonomy, and bringing out its complexity and ambivalence through two examples from our clinical practice: the shared decision-making process for patients with localized prostate cancer and the patient's involvement in the success of his radiotherapy. [ABSTRACT FROM AUTHOR]

Résumé Le traitement de référence des tumeurs de vessie infiltrant le muscle est la cystectomie totale. La chimioradiothérapie concomitante s’est imposée comme une alternative thérapeutique à une chirurgie radicale en vue d’une stratégie de conservation vésicale ou chez un patient non opérable du fait de maladies associées. L’analyse des données de la littérature montre des taux de contrôle local avec conservation vésicale à 5 ans de 40 à 65 %, et une probabilité de survie globale de 40 à 50 % à 5 ans avec une qualité de vie excellente. Cet article établit les recommandations françaises pour la réalisation de la radiothérapie des cancers de vessie : indications, examens nécessaires, technique, dosimétrie, délivrance et guidage par l’image. Surgery (radical cystectomy) is the standard treatment of muscle-invasive bladder cancer. Radiochemotherapy has risen as an alternative treatment option to surgery as part as organ-sparing combined modality treatment or for patients unfit for surgery. Radiochemotherapy achieves 5-year bladder intact survival of 40 to 65% and 5-year overall survival of 40 to 50% with excellent quality of life. This article introduces the French recommendations for radiotherapy of bladder cancer: indications, exams, technique, dosimetry, delivery and image guidance. [ABSTRACT FROM AUTHOR]

Résumé L’effet du fractionnement de la dose d’irradiation est une question récurrente qui reste globalement irrésolue car aucun modèle ne permet aujourd’hui de déduire l’effet clinique par la seule donnée de la dose cumulée et des caractéristiques radiobiologiques des tissus irradiés. Cette question importante est abordée différemment en radioprotection, radiothérapie, radiologie ou épidémiologie. Une meilleure compréhension de la réponse moléculaire aux radiations rend aujourd’hui possible une approche nouvelle pour identifier les paramètres qui conditionnent l’effet du fractionnement. En particulier, l’intervalle de temps entre les doses apparaît comme un facteur essentiel puisqu’il permettra, ou non, la réparation de certains dommages radio-induits de l’ADN comme les dommages de bases, les cassures simple-brin ou les cassures double-brin dont les rythmes de réparation sont respectivement de l’ordre de la seconde, de la minute ou de l’heure : l’effet de fractionnement variera alors suivant les statuts fonctionnels de ces voies de réparation, que ce soit pour les tissus sains comme pour les tumeurs. The dose fractionation effect is a recurrent question of radiation biology research that remains unsolved since no model predicts the clinical effect only with the cumulated dose and the radiobiology of irradiated tissues. Such an important question is differentially answered in radioprotection, radiotherapy, radiology or epidemiology. A better understanding of the molecular response to radiation makes possible today a novel approach to identify the parameters that condition the fractionation effect. Particularly, the time between doses appears to be a key factor since it will permit, or not, the repair of certain radiation-induced DNA damages whose repair rates are of the order of seconds, minutes or hours: the fractionation effect will therefore vary according to the functionality of the different repair pathways, whatever for tumor or normal tissues. [ABSTRACT FROM AUTHOR]

Résumé Introduction L’hématopoïèse extra-médullaire (HE) symptomatique par compression des organes adjacents est une complication rare mais potentiellement sévère des β-thalassémies. Son traitement est mal codifié. Méthodes Étude descriptive rétrospective monocentrique des cas d’HE symptomatiques diagnostiqués entre 1997 et 2014 dans un centre de référence pour le traitement des maladies génétiques du globule rouge. Description des caractéristiques cliniques et paracliniques, des traitements entrepris et de l’évolution. Résultats Sur 182 patients β-thalassémiques suivis sur la période d’étude, 7 cas d’HE symptomatique étaient retrouvés. Il s’agissait de 5 hommes et 2 femmes d’âge moyen 37 ans. Quatre patients étaient splénectomisés, 2 patients étaient sous programme transfusionnel régulier, et 4 patients avaient déjà reçu de l’érythropoïétine recombinante. L’HE était de siège intravertébral dorsal responsable de compression médullaire dans 5 cas, paravertébral dorsal dans un cas, et présacré dans un cas. Le taux d’hémoglobine moyen au diagnostic de l’HE était de 7,9 g/dL. Le traitement a consisté pour 6 patients en des transfusions érythrocytaires, associées à l’hydroxyurée (HU) dans 5 cas et/ou à la radiothérapie dans 3 cas. Un patient a été traité par chirurgie puis HU sans transfusion. Avec une durée médiane de suivi de 41 mois, l’évolution clinique était totalement favorable chez 2 patients, avec des séquelles chez 5 patients. Conclusion Le diagnostic d’HE doit être suspecté chez un patient β-thalassémique présentant des signes cliniques de compression d’organe et un aspect radiologique évocateur. Le traitement, dont la rapidité conditionne le pronostic, doit associer les transfusions globulaires, l’hydroxyurée, plus ou moins la radiothérapie. Le recours à la chirurgie est exceptionnel. Les séquelles sont fréquentes. Introduction Symptomatic extramedullary hematopoiesis (EH) is a rare but potentially severe phenomenon which occurs in β-thalassemia. There are no treatment guidelines. Methods Retrospective single centre study including the cases of symptomatic EH encountered between 1997 and 2014 in a unit specialised in red blood cell genetic disorders. Description of clinical, biological and radiological characteristics of the patients, treatments received, and outcomes. Results Among 182 β-thalassemia patients followed during the study period, 7 cases of symptomatic EH were diagnosed. They were 5 men and 2 women, and their mean age was 37 years. Four patients were splenectomised, two patients were regularly transfused, and four patients had already received erythropoietin. EH was localised in intravertebral areas and responsible for dorsal spinal cord compression in 5 patients, in paravertebral dorsal area in 1 patient, and in presacral area in 1 patient. The mean hemoglobin level at diagnosis was 7.9 g/dL. Treatment administered included: red cell transfusion in 6 cases, associated with hydroxyurea in 5 cases and/or radiotherapy in 3 patients. One patient was treated with surgery and HU. After a median follow-up of 41 months, clinical recovery was complete in 2 patients and partial in 5 patients. Conclusion EH must be suspected in β-thalassemia in patients presenting clinical signs of organ compression, and a typical radiological aspect. The functional prognosis depends on the rapidity of treatment, which includes red blood cell transfusion, hydroxyurea, radiotherapy, and rarely surgery. Long-term outcome is uncertain. [ABSTRACT FROM AUTHOR]

Résumé La radiothérapie antalgique des métastases osseuses de première intention est un traitement efficace quel que soit le fractionnement (traitement non ou plurifractionné). La radiothérapie peut également être proposée en cas d’échec ou d’efficacité insuffisante d’une première irradiation (après avoir éliminé une fracture) ou l’apparition de nouveaux sites douloureux. Les autres indications sont les compressions médullaires après la chirurgie ou exclusivement, et les irradiations après chirurgie pour métastase des os longs. Le développement de la radiothérapie de haute précision (en conditions stéréotaxiques) augmente les possibilités de réirradiation lorsque les doses maximales admissibles par les tissus sains ont été atteintes. Elle cherche à améliorer la probabilité de contrôle local, voire celle de survie, en cas de maladie oligométastatique. First-line palliative radiotherapy for painful bone metastases is an effective treatment whatever its fractionation (single or multiple fractions). It is also indicated after failure or insufficient effect of a first irradiation, or the appearance of new painful site. Other indications are spinal cord compression, either as an adjuvant to surgery or as sole treatment, and after surgery for long bone metastases. The development of high precision techniques (stereotactic conditions) widens the possibility of re-irradiation when tolerance doses to normal tissues have already been delivered. Local control and possibly overall survival could be improved in oligometastatic patients. [ABSTRACT FROM AUTHOR]

There is limited level 1 evidence for the role of curative radiotherapy in older patients. The evidence base for commonly treated solid tumours is reviewed. Best practice and research priorities are presented.Radiotherapy (RT) is a key component of the management of older cancer patients. Level I evidence in older patients is limited. The International Society of Geriatric Oncology (SIOG) established a task force to make recommendations for curative RT in older patients and to identify future research priorities. Evidence-based guidelines are provided for breast, lung, endometrial, prostate, rectal, pancreatic, oesophageal, head and neck, central nervous system malignancies and lymphomas. Patient selection should include comorbidity and geriatric evaluation. Advances in radiation planning and delivery improve target coverage, reduce toxicity and widen eligibility for treatment. Shorter courses of hypofractionated whole breast RT are safe and effective. Conformal RT and involved-field techniques without elective nodal irradiation have improved outcomes in non-small-cell lung cancer (NSCLC) without increasing toxicity. Where comorbidities preclude surgery, stereotactic body radiotherapy (SBRT) is an option for early-stage NSCLC and pancreatic cancer. Modern involved-field RT for lymphoma based on pre-treatment positron emission tomography data has reduced toxicity. Significant comorbidity is a relative contraindication to aggressive treatment in low-risk prostate cancer (PC). For intermediate-risk disease, 4–6 months of hormones are combined with external beam radiotherapy (EBRT). For high-risk PC, combined modality therapy (CMT) is advised. For high-intermediate risk, endometrial cancer vaginal brachytherapy is recommended. Short-course EBRT is an alternative to CMT in older patients with rectal cancer without significant comorbidities. Endorectal RT may be an option for early disease. For primary brain tumours, shorter courses of postoperative RT following maximal debulking provide equivalent survival to longer schedules. MGMT methylation status may help select older patients for temozolomide alone. Stereotactic RT provides an alternative to whole-brain RT in patients with limited brain metastases. Intensity-modulated radiation therapy provides an excellent technique to reduce dose to the carotids in head and neck cancer and improves locoregional control in oesophageal cancer. Best practice and research priorities are summarised. [ABSTRACT FROM PUBLISHER]

In this retrospective study we should that adjuvant radiotherapy efficiently prevents recurrence of atypical lipomatous tumors (also called well differenciated liposarcomas of the extremities and trunk wall). However because these tumors are considered benign, the risk of morbidity due to tumor recurrence should be carefully weighted against that of radiation induced tumors.Background The role of adjuvant radiotherapy (RT) in the management of atypical lipomatous tumor/well-differentiated liposarcoma (ALT/WD-LPS) remains controversial. Methods Two hundred eighty-three patients with operable ALT/WD-LPS, no history of previous cancer, chemotherapy (CT) or RT, treated between 1984 and 2011 registered in the Conticabase database were included and described. Overall (OS), progression-free survival (PFS) and time to local relapse (TTLR) were evaluated from the time of first treatment. Results Three of 20 centers enrolled 58% of the patients. Median age at diagnosis was 61 (range 25–94) years, 147 patients (52%) were males, 222 (78%) patients had their primary tumor located in an extremity while 36 (13%) and 25 (9%) had tumors involving the girdle and the trunk wall, respectively. The median size of primary tumors was 17 cm (range 2–48 cm). Adjuvant RT was given to 132 patients (47%). Patients who received adjuvant RT had larger tumors (P = 0.005), involving more often the distal limbs (P < 0.001). Use of adjuvant RT varied across centers and along the study period. Other characteristics were balanced between the two groups. Median follow-up was 61.7 months. None of the patients developed metastasis during follow-up. The 5-year local relapse-free survival rates were 98.3% versus 80.3% with and without adjuvant RT, respectively (P < 0.001). Once stratified on time period (before/after 2003), adjuvant RT, tumor site and margin status (R0 versus other) were independently associated with TTLR. No OS difference was observed (P = 0.105). Conclusion In this study, adjuvant RT following resection of ALT/WD-LPS was associated with a reduction of LR risk. [ABSTRACT FROM AUTHOR]

Résumé: La cystectomie radicale est le traitement de référence du carcinome infiltrant de la vessie, mais le traitement conservateur est une option pour des patients sélectionnés. Il comprend une résection transurétrale de la vessie la plus complète possible et une chimioradiothérapie concomitante. Les mouvements des parois vésicales au cours de la radiothérapie justifient l’utilisation de marges importantes pour couvrir de façon satisfaisante le volume cible anatomoclinique. Les marges formant le volume cible prévisionnel doivent être adaptées au degré de mobilité de chaque portion de la vessie, et donc anisotropiques : de l’ordre de 10mm au niveau du trigone, 15mm latéralement, et 20 à 25mm au niveau de la paroi antérieure et du dôme. Elles peuvent être diminuées en cas de radiothérapie guidée par l’image. Ces marges sont probablement amenées à diminuer, avec le développement du guidage par l’image en routine et de la radiothérapie adaptative. Par ailleurs, la radiothérapie partielle de la vessie montre des résultats prometteurs chez des patients sélectionnés et permet de réduire considérablement le volume irradié. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To report retrospective long-term results of historical experience of breast radiotherapy (RT) including external beam radiotherapy (EBRT) followed by low dose rate (LDR) brachytherapy. Patients and methods: Between 1971 and 1983, at our service 474 breast cancer patients underwent exclusive conserving radiotherapy treatment. The RT included an initial external irradiation followed by interstitial LDR brachytherapy (37Gy) to the residual tumour. The local regional nodes received 47.5Gy followed by a 15Gy boost delivered to the mammary nodes internal (IMN) and 25Gy axilla. Results: Median follow-up was 139months (8–342). There were 40 T1, 356 T2, and 78 T3. Local recurrences (LR) were observed in 20% of cases. The rate of recurrences free at 5, 10, 15 and 20years were 86%, 77%, 73% and 67% respectively. At 5, 10, 15 and 20-year, the disease-free survival rates were 63%, 42%, 32% and 24%. Overall survival rates at 5, 10, 15 and 20-years were 75%, 53%, 34% and 25% respectively. Conclusion: Although the historical retrospective character of these series, it is interesting to have this experience and to analyse it according to our new knowledge and advances. The described technique was a standard for many years and could be still used in some cases. [Copyright &y& Elsevier]

Abstract: Purpose: The main objective of the economical study was to prospectively and randomly assess the additional costs of daily versus weekly patient positioning quality control in image-guided radiotherapy (IGRT), taking into account the modalities of the 3D-imaging: tomography (CBCT) or gold seeds implants. A secondary objective was to prospectively assess the additional costs of 3D versus 2D imaging with portal imaging for patient positioning controls. Patients and methods: Economics data are issued from a multicenter randomized medico-economics trial comparing the two frequencies of patient positioning control during prostate IGRT. A prospective cohort with patient positioning control with PI (control group) was constituted for the cost comparison between 3D (IGRT) versus 2D imaging. The economical evaluation was focused to the radiotherapy direct costs, adopting the hospital''s point of view and using a microcosting method applied to the parameters that may lead to cost differences between evaluated strategies. Results: The economical analysis included a total of 241 patients enrolled between 2007 and 2011 in seven centres, 183 in the randomized study (128 with CBCT and 55 with fiducial markers) and 58 in the control group. Compared to weekly controls, the average additional cost per patient of daily controls was €847 (CBCT) and €179 (markers). Compared to PI, the average additional cost per patient was €1392 (CBCT) and €997 (fiducial markers) for daily controls; €545 (CBCT) and €818 (markers) in case of weekly controls. Conclusion: A daily frequency for image control in IGRT and 3D images patient positioning control (IGRT) for prostate cancer lead to significant additional cost compared to weekly control and 2D imaging (PI). Long-term clinical assessment will permit to assess the medico-economical ratio of these innovative radiotherapy modalities. [Copyright &y& Elsevier]

Abstract: Solitary metastases have been reported in up to 30% of cases in imaging series. Local treatment aims at consolidating the injured bone and to prevent neurologic complications. Since the prognosis of bony metastatic disease is about 30months and includes some long survivors, the multisdisciplinary committee in charge of the patient should ask the question and decide on the type of radical/ablative intervention in case of oligometastases. A literature search was performed using MESH terms (bone, metastases, radiotherapy, radiology, cement, radiofrequency ablation, chemoembolisation). Local ablative treatments can yield symptomatic relief and local control rates of about 90%. Stereotactic hypofractionated irradiation and cementoplasty are increasingly used. In conclusion, local ablative treatment of bony oligometastases is an efficient treatment. Its potential impact on survival remains to be demonstrated prospectively in clinical trials. [Copyright &y& Elsevier]

Abstract: Purpose: To assess interfraction and intrafraction bladder wall movements in the different anatomic portions of the bladder. Patients and methods: Six patients were treated for prostate cancer with conformal irradiation. Daily online cone beam computed tomography was performed for repositioning and an additional one was performed following irradiation once weekly. Four craniocaudal levels were defined to calculate movements amplitudes compared to the scanner tracking: level 1 at the bladder neck, level 2 at mid-height of the bladder, level 3 at mid-height of the dome, level 4 at the apex in a distended bladder. Bladder height was also measured. Results: On 198 daily cone beam computed tomographies, radial bladder right/left/anterior/posterior wall displacements at level 2 were 0.08±0.24, 0.11±0.33, 0.16±0.45 and 0.14±0.50cm and at level 3 0.07±0.78, 0.18±0.98, 0.43±0.94 and 0.04±1.02cm. Dome and neck displacements were 0.08±1.41cm and 0.08±0.64cm. Seventeen cone beam computed tomographies were done following irradiation. Radial bladder right/left/anterior/halfway up the trine wall displacements at level 2 before and after irradiation were 0.02±0.18, 0.01±0.30, 0.09±0.32 and 0.22±0.42cm and at level 3 0.27±0.60, 0.37±1.15, 0.18±0.87 and 0.54±1.68cm. Conclusion: Significant bladder wall displacements were observed on the anterior wall and upper portion of the bladder. Isotropic margins may not be sufficient to account for inter- and intrafraction bladder wall displacements at the latter levels. Tailored bladder anatomy-based anisotropic margins may be necessary to optimally spare the small intestine and to guaranty proper tumour coverage in case of bladder cancer. For upper bladder tumours, margins of over 2cm would be necessary, which make them less adequate for external beam irradiation. [Copyright &y& Elsevier]

Abstract: Image-guided radiotherapy (IGRT) combined or not with intensity-modulated radiation therapy (IMRT) are new and very useful techniques. However, these new techniques are responsible of irradiation at low dose in large volumes. The control of alignment, realignment of the patient and target positioning in external beam radiotherapy are increasingly performed by radiological imaging devices. The management of this medical imaging depends on the practice of each radiotherapy centre. The physical doses due to the IGRT are however quantifiable and traceable. In one hand, these doses appear justified for a better targeting and could be considered negligible in the context of radiotherapy. On the other hand, the potential impact of these low doses should deserve the consideration of professionals. It appears important therefore to report and consider not only doses in target volumes and in “standard” organs at risk, but also the volume of all tissue receiving low doses of radiation. The recent development of IMRT launches the same issue concerning the effects of low doses of radiation. Indeed, IMRT increases the volume of healthy tissue exposed to radiation. At low dose (<100mGy), many parameters have to be considered for health risk estimations: the induction of genes and activation of proteins, bystander effect, radio-adaptation, the specific low-dose radio-hypersensitivity and individual radiation sensitivity. With the exception of the latter, the contribution of these parameters is generally protective in terms of carcinogenesis. An analysis of secondary cancers arising out of field appears to confirm such notion. The risk of secondary tumours is not well known in these conditions of treatment associating IMRT and IGRT. It is therefore recommended that the dose due to imaging during therapeutic irradiation be reported. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To investigate if the regular use of kV-CBCT notably increases the dose delivered to tumor and surrounding healthy tissues. Material and methods: Images were obtained using a Varian™ equipment (OBI version 1.3, 645 to 650 projections in 370° to acquire image), and patients were irradiated at source–tumor distance: 100cm. In vivo measurements were performed using radio-thermoluminescent dosimeters Harshaw-TLD700H (TLD) at skin (anterior–posterior and lateral axis crossing the rotation axis), with a fourth TLD group under the table thanks to a retrolaser. TLD''s were calibrated at the kV-CBCT effective energy (64 keV), and the method validated using an anthropomorphic phantom, in which Gafchromic EBT films were also inserted. Results: The phantom study showed that the dose distribution depends on the phantom position relative to the axis and that the doses measured at the phantom surface using TLD and films (good agreement) were maximum at the entrance of the anterior–posterior axis. Their arithmetic mean was equal, or a slightly greater than doses measured at mid-thickness of the phantom and at the level of the rectum (OAR). In vivo measurements performed on the five first patients (125 kV-CBCT) yield a mean skin dose per kV-CBCT varying from 5.8±0.1 to 7.3±0.2 cGy on the anterior–posterior axis. Lateral skin doses vary from 3.4±0.2 to 4.5±0.2 cGy. Conclusion: Doses delivered by repeated kV-CBCT are not negligible. They should be taken into account, but questions about the RBE to be applied to kilovoltage X-rays are raised. [Copyright &y& Elsevier]

Abstract: Ductal carcinoma in situ is defined as breast cancer confined to the ducts of the breast without evidence of penetration of the basement membrane. Local treatment quality represents one of the most prognostic factors as half of recurrences are invasive diseases. The main goal of adjuvant radiotherapy after conservative surgery is to decrease local recurrences and to permit breast conservation with low treatment-induced sequelae. Several randomized trials have established the impact of 50Gy to the whole breast in terms of local control. Nevertheless, no randomized trial is still available concerning the role of the boost in this disease. In this review, we present updated results of the literature and we detail the French multicentric randomized trial evaluating the impact of a 16Gy boost after 50Gy delivered to the whole breast in 25 fractions and 33 days. This protocol will start inclusions in October 2008. [Copyright &y& Elsevier]

Abstract: Recent advances in radiation oncology are based on improvement in dose distribution thanks to IMRT and improvement in target definition through new diagnostic imaging such as spectroscopic or functional MRI or PET. However, anatomic variations may occur during treatment decreasing the benefit of such optimization. Image-guided radiotherapy reduces geometric uncertainties occurring during treatment and therefore should reduce dose delivered to healthy tissues and enable dose escalation to enhance tumour control. However, IGRT experience is still limited, while a wide panel of IGRT modalities is available. A strong quality control is required for safety and proper evaluation of the clinical benefit of IGRT combined or not with IMRT. [Copyright &y& Elsevier]

Purpose. – Intra-operative intertitial brachytherapy has been applied in the curative and palliative treatment of lung cancer. Implantation of radio-active sources offers an advantage over external irradiation because of the limited penetrability from source to prescription point, resulting in rapid dose fall-off and sparing of surrounding normal tissues. The aim of this study was to re-evaluate retrospectively the Antoine-Lacassagne cancer center experience in endobronchial brachytherapy by low dose rate (LDR) or high dose rate (HDR) and to design perspectives for the next decades. Evaluation was based on analysis of toxicities, response rates and survival. Materials and methods: From october 1989 to june 1999, 31 consecutive patients with bronchogenic carcinoma were treated. Thirteen and 18 patients received LDR and HDR, respectively. The mean age was 65 years (range 44 to 79 years). Inclusion criteria were, for palliative treatment, incurable endobronchial cancer, and for curative treatment, residual tumor in the margins after resection, or endobronchial tumor could not be treated surgically. Exclusion criteria were sites of lesion unsuitable for placement of the brachytherapy catheter. Evaluation of complications and clinical response were based on endoscopic evaluation one month after the last session and at less one year after the end of treatment.Results. – Eighty-seven courses have been performed: 65 by LDR and 22 by HDR. Thirty-six courses have been performed in the palliative group, 51 courses in the curative group. Seven patients among 31 presented acute complications and 18/31 late complications. Complete global response rate was 14/30 evaluable patients (47%). Mean overall global survival was 23 months with a median follow-up of 3.5 years.Conclusion. – These results confirm the efficacy of endobronchial brachytherapy as well as palliative or curative treatment, but the improvement of results will essentially depend on our capacity to better define our indications and underlie the necessity to perform phase III international randomised trial. [Copyright &y& Elsevier]

Résumé La radiothérapie garde une place majeure dans la prise en charge des métastases osseuses. Elle est principalement utilisée dans un but palliatif à visée antalgique ou décompressive. De façon plus récente, les développements de la radiothérapie stéréotaxique et de la radiothérapie conformationnelle avec modulation d’intensité laissent entrevoir son utilisation à dose curative dans la maladie oligométastatique. L’objectif de cet article est de rapporter les indications et les modalités de la radiothérapie dans ces différentes situations. Radiotherapy plays a major role in palliative treatment of bone metastases. Recent developments of stereotactic radiotherapy and intensity modulated radiation therapy give the possibility to treat oligometastatic diseases. The objective of this paper is to report indications and treatment modalities of radiotherapy in these situations. [ABSTRACT FROM AUTHOR]