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La gestione terapeutica dei pazienti adulti con tumori cerebrali e multidisciplinare e la radioterapia costituisce una delle principali opzioni terapeutiche. L’efficacia della radioterapia e stata evidenziata nel trattamento di piu tumori intracranici, benigni o maligni. Il ricorso a una diagnostica per immagini multimodale, l’emergere di approcci terapeutici innovativi (radioterapia conformazionale mediante modulazione di intensita, terapia protonica, radioterapia stereotassica) e i progressi dei sistemi di verifica del posizionamento hanno contribuito a migliorare la precisione delle tecniche di trattamento. I tessuti sani sono protetti meglio mantenendo contemporaneamente alti livelli di dosaggio in corrispondenza dei volumi bersaglio. Sono stati, inoltre, sviluppati protocolli di radioterapia individualizzati, adattati all’eta e alle condizioni generali dei pazienti. Le attuali sperimentazioni cliniche mirano a valutare il rapporto beneficio/rischio di nuove associazioni terapeutiche e a ridurre l’incidenza degli effetti secondari cognitivi indotti dai trattamenti oncologici.

Purpose With the increasing use of simultaneous integrated boost in the treatment of cervical cancer, there is a need to anticipate the brachytherapy (BT) contribution at the level of the pathologic pelvic lymph nodes. This study aimed to report the dose delivered at their level during BT. Methods and Materials Patients with pelvic nodal involvement and treated with a combination of chemoradiation followed by image-guided adaptive pulsed-dose-rate BT were selected. On per BT three-dimensional images, pelvic lymphadenopathies were delineated, without planning aim. For the purposes of the study, D100, D98, D90, and D50 were reviewed and converted in 2-Gy equivalent doses, using the linear quadratic model with an α/β of 10 Gy. Results Ninety-one patients were identified, allowing evaluation at the level of 226 lymphadenopathies. The majority of them were external iliac (48%), followed by common iliac (25%), and internal iliac (16%) regions. The 2-Gy equivalent doses D98 were 4.4 ± 1.9 Gy, 5.4 ± 3.1 Gy, and 4.3 ± 2.1 Gy for the obturator, internal iliac, and external iliac, respectively, and 2.8 ± 2.5 Gy for the common iliac. The contribution to the common iliac nodes was significantly lower than the one of external and internal iliac (p Conclusions BT significantly contributes to the treatment of pelvic nodes at the level of approximately 5 Gy in the internal, external, and obturator areas and 2.5 Gy in the common iliac, allowing the anticipation of nodal boost with the simultaneous integrated boost technique. However, important individual variations have been observed, and evaluation of the genuine BT contribution should be recommended.

International audience; The objective of the study was to evaluate the outcomes of a large consecutive series of 362 patients with renal cell carcinoma (RCC) brain metastases using stereotactic radiosurgery (SRS) in the tyrosine kinase inhibitor (TKI) era. Sixty-one patients (226 metastases) were treated using Gamma-Knife and 63 patients (136 metas-tases) using linear accelerator. The association of SRS with TKI is highly efficient in brain metastases from RCC and, appears safe and avoids whole-brain radiotherapy. Background: The objective of the study was to evaluate the outcomes in terms of efficacy and safety of a large consecutive series of 362 patients with renal cell carcinoma (RCC) brain metastases treated using stereotactic radi-osurgery (SRS) in the tyrosine kinase inhibitor (TKI) era. Patients and Methods: From 2005 to 2015, 362 consecutive patients with brain metastases from RCC were treated using SRS in 1 fraction: 226 metastases (61 patients) using Gamma-Knife at a median of 18 Gy (50% isodose line); 136 metastases (63 patients) using linear accelerator at a median of 16 Gy (70% isodose line). The median patient age was 58 years. At the first SRS, 37 patients (31%) received a systemic treatment. Among systemic therapies, TKIs were the most common (65%). Results: The local control rates were 94% and 92% at 12 and 36 months, respectively. In multivariate analysis, a minimal dose >17 Gy and concomitant TKI treatment were associated with higher rates of local control. The overall survival rates at 12 and 36 months were 52% and 29%, respectively. In multivariate analysis, factors associated with poor survival included age !65 years, lower score index for SRS, concomitant lung metastases, time between RCC diagnosis and first systemic metastasis 4 months, occurrence during treatment with a systemic therapy, no history of neurosurgery, and persistence or occurrence of neurological symptoms at 3 months after SRS. Seventeen patients had Grade III/IV adverse effects of whom 3 patients presented a symptomatic radionecrosis. Conclusion: SRS is highly effective in patients with brain metastases from RCC. Its association with TKIs does not suggest higher risk of neurologic toxicity.

Installation and use of a new radiotherapy device require an adequate quality and safety policy. The process leading to the commissioning of an accelerator following the construction of a bunker includes, among other tasks, the installation of the accelerator, the verification of compliance with the specifications, the signature of the acceptance specification as well as the process of characterization and modeling of the accelerator before its clinical use. The emergence of modern radiotherapy techniques, such as intensity modulated conformational radiotherapy and stereotactic radiotherapy, has resulted in more complex quality controls. The purpose of this article is to explain the different stages of the implementation of innovative radiotherapy techniques and to specify their features.

Meningiomas account for 30–35% of intracranial tumors. Grade I meningiomas are most common and carry the best prognosis. Grade II and III meningiomas are more aggressive and the outcomes after surgical resection alone remain unsatisfactory. The main objective of this retrospective, single-center study was to assess our results of treatment of grade II–III intracranial meningioma with helical tomotherapy (HT). We retrospectively reviewed patients with histologically proven (WHO 2007) grade II–III meningioma irradiated with HT. Patients were treated one session a day, 5 days a week, to a total dose of 59.4 Gy and 68.4 Gy delivered in 33 and 38 fractions of 1.8 Gy each to the LR PTV and HR PTV, with or without simultaneous integrated boost. From May 2011 to January 2015, 19 patients (15 with grade II and 4 with grade III meningiomas) were treated. Median follow-up for patients with Grade II or Grade III meningiomas, was 29.2 months (range, 10.7–52.4) and 21.3 months (range, 2.4–51.3), respectively. Disease free survival at 1, 2 and 3 years was 89.2%, 83.6% and 56.3% respectively. Overall survival at 1, 2 and 3 years was 94.7%, 94.7% and 78.9%, respectively. No patient had neurological toxicity greater than grade 2 in the acute period. During follow-up, only one patient had neurological toxicity greater than or equal to grade 3. The management of grade II to III meningiomas using HT with doses exceeding 60 Gy is associated with good local control and acceptable survival results.

Objective To describe a surgical technique for laparoscopic uterine fixation (LUF) to decrease uterine radiation therapy side effects in case of rectal or anal cancer. Design This video article uses a surgical case to demonstrate the detailed technique. Institutional Review Board approval was not required for this video presentation. Setting University hospital. Patient(s) A 26-year-old nulliparous female patient diagnosed with rectal adenocarcinoma and liver metastases. After the completion of right hepatectomy and neoadjuvant chemotherapy with the use of the FOLFOX regimen, pelvic radiation therapy was applied before tumor excision. Intervention(s) The patient underwent laparoscopic ovarian transposition. During the same intervention, we fixed the uterus with three late resorbable sutures into the fascia of the anterior abdominal wall as cranial as possible to remove the uterus away from the radiation field. Main outcome measure(s) Value and feasibility of LUF. Result(s) LUF was feasible and effective. Estimated isodoses demonstrated that this intervention may decrease uterine consequences of pelvic radiotherapy. The patient did not report any specific pain or complication in the postoperative period. Three months after the completion of pelvic concurrent chemoradiation therapy, the patient had normal menstrual periods. Hormonal blood tests were satisfactory. Ultrasound showed persistent ovarian function. Conclusion(s) Considering its simplicity of realization, LUF should be discussed for reproductive-age patients before undergoing pelvic radiotherapy for anal or rectal cancer. A close collaboration is required between surgeons and radiation oncologists to optimize the treatment and to decrease side-effects of radiotherapy. Intensity-modulated radiation therapy may contribute to enhance a multimodal fertility-sparing strategy in global management of young patients.

Resume Les cancers de l’œsophage localement evolues relevent d’une prise en charge pluridisciplinaire ou la chimioradiotherapie occupe une place essentielle. La chimioradiotherapie neoadjuvante permet d’ameliorer les taux de controle locoregional et de survie globale des cancers de l’œsophage localement evolues operes. La chimioradiotherapie exclusive a egalement une place pour les lesions non resecables et/ou pour les patients non operables et est consideree comme une alternative a la chirurgie dans la prise en charge initiale des carcinomes epidermoides de l’œsophage localement evolues. La chimiotherapie associee consiste en une combinaison de sels de platine (cisplatine ou oxaliplatine) et de 5-fluoro-uracile le plus souvent, ou de carboplatine et de paclitaxel hebdomadaire selon le protocole CROSS en situation neoadjuvante. Les doses varient de 41,4 Gy (protocole CROSS) a 45 Gy en situation neoadjuvante. En traitement exclusif, une dose de 50 a 50,4 Gy est preconisee selon les recommandations francaises et americaines. Les volumes cibles tiennent compte des particularites anatomiques de l’œsophage et de son drainage lymphatique. Ainsi, une irradiation ganglionnaire prophylactique interesse classiquement les aires ganglionnaires presentant un risque d’envahissement de plus de 15 % a 20 %. L’utilisation de la radiotherapie conformationnelle avec modulation d’intensite represente une approche prometteuse susceptible de diminuer la toxicite dans les organes a risque adjacents. Cet article decrit, a partir d’une revue critique de la litterature, la place de la chimioradiotherapie dans la strategie therapeutique, les volumes anatomiques d’interet, les doses de prescription, les contraintes de doses dans les organes a risque et les techniques de radiotherapie adaptees.

Resume Les techniques modernes de radiotherapie (radiotherapie conformationnelle avec modulation d’intensite [RCMI], arctherapie volumetrique modulee, radiotherapie guidee par l’imagerie) ou la radiotherapie stereotaxique se democratisent dans la plupart des centres de radiotherapie en France. L’arrivee de ces nouvelles techniques passe par la mise a jour des systemes de radiotherapie deja en place ou par l’installation de nouveaux appareils avec des options adaptees. Avec l’arrivee de ces nouveaux appareils il devient necessaire de developper une politique de qualite et de surete au sein des departements de radiotherapie. Cette politique permet de faciliter la mise en place de nouveaux appareils de l’installation du materiel jusqu’au premier patient traite. La politique de qualite et de surete se poursuit ensuite pour maintenir un controle de la qualite permanent et continu du nouvel appareil. Dans cet article, nous avons donc fait une revue de la litterature sur la politique de qualite et de surete dans le cadre legal francais qui peut etre proposee lors de l’arrivee d’un nouvel appareil de radiotherapie.

Purpose Primary vaginal cancer is a rare disease for which treatment has been modeled based on cervical cancer. We report our experience in the use of image-guided adaptive brachytherapy (IGABT) in this indication. Methods and Materials Patients treated for vaginal cancer with a combination of external beam radiation therapy and IGABT were identified through electronic search. The Groupe Europeen de Curietherapie–European Society for Radiotherapy and Oncology recommendations for cervical cancer have been extrapolated with the definition of two clinical target volumes (CTVs) corresponding to the residual disease after external beam radiation therapy (CTVBT), assessed from clinical and imaging findings, and the so-called CTVi, comprising the CTVBT with directional margins and at least the initial disease at diagnosis. Results Twenty-seven patients were identified. MRI was used for brachytherapy guidance in 82% of the cases. An interstitial component was used in 59% of the cases. The D90 CTVBT and D90 CTVi were 73.1 ± 12.8 Gy and 66.6 ± 6.7 Gy, respectively. After a median followup of 40.1 months, nine recurrences in 8 patients were observed of which four were local. Local relapses occurred within the CTVBT. Three-year local control and disease-free rates were 82% and 65%, respectively. At 2 years, the Grade 2–4 gastrointestinal or urinary morbidity accrual rate was 9%. Twelve patients experienced late sexual morbidity, including three patients with Grade 3 stenosis. Conclusion IGABT is feasible in vaginal cancer with promising outcomes. Harmonizing the definition of CTVs is required to allow comparisons between experiences and to perform multicenter studies.

International audience; The treatment of rectal carcinoma is based on multidisciplinary strategy and multimodal approaches including gastrointestinal tract specialists, medical oncologists, radiation oncologists and surgery. The different objectives should be declined according to the characteristics of the tumours. The aim of the therapist would be to select the best strategy offering to the patient to be cured with as less as possible late adverse toxicity. The challenge of the treatment of small tumours is to maintain a functional anal sphincter while minimizing the risk of local recurrence. The standard treatment of locally advanced disease is aiming firstly to cure the patient and secondly to prevent late complications. Each of these clinical presentations of the disease has to be considered as a whole taking into account the new surgical techniques and a personalized approach adapted to the tumour. Nowadays they should be studied with dedicated clinical trials.; Le traitement des cancers du rectum repose sur une prise en charge pluridisciplinaire et le plus souvent sur une approche multimodale comprenant la gastro-entérologie, l’oncologie médicale, l’oncologie–radiothérapie et la chirurgie. Les différents objectifs qui doivent être discriminés dépendent des caractéristiques de la tumeur. Le défi de la prise en charge des petites tumeurs repose sur la conservation d’un sphincter fonctionnel sans risque de récidive locale. Le traitement standard des maladies localement évoluées vise, par ordre de priorité, à guérir le malade en minimisant les séquelles tardives de la prise en charge. Chacune de ces situations cliniques se trouve désormais démembrée grâce aux progrès de la chirurgie et d’une approche personnalisée au patient à la caractéristique clinique de la maladie. Elles sont désormais l’objet d’études thérapeutiques spécifiques.

Purpose Conflicting results concerning the toxicity of radiotherapy in the setting of rheumatoid arthritis were reported in literature. This work describes the toxicity profiles of patients with rheumatoid arthritis undergoing pelvic radiotherapy for gynecologic malignancies at our institution. Patients and methods Charts of patients with rheumatoid arthritis who underwent pelvic radiotherapy for cervical or endometrial cancer in a curative intent at the Gustave-Roussy Cancer Campus between 1990 and 2015 were reviewed for treatment-related toxicities. Acute and late effects were graded as per the Common Terminology Criteria for Adverse Events version 4.0 scoring system. Results Eight patients with cervical cancer and three with endometrial cancer were identified. Median follow-up was 56 months. Median external beam radiotherapy dose was 45 Gy. All patients received a brachytherapy boost using either pulse- or low-dose rate technique. Concomitant chemotherapy was used in seven cases. Median time from rheumatoid arthritis diagnosis to external beam radiation therapy was 5 years. No severe acute gastrointestinal or genitourinary toxicity was reported. One patient had grade 3 dermatitis. Any late toxicity occurred in 7 /11 patients, and one patient experienced severe late toxicities. One patient with overt systemic rheumatoid arthritis symptoms at the time of external beam radiation therapy experienced late grade 3 ureteral stenosis, enterocolitis and lumbar myelitis. Conclusion Pelvic radiotherapy, in the setting of rheumatoid arthritis, appears to be feasible, with potentially slight increase in low grade late events compared to other anatomic sites. Patients with overt systemic rheumatoid arthritis manifestation at the time of radiotherapy might be at risk of potential severe toxicities.