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Background and Purpose: To assess the late effect of a prostaglandin, given rectally during irradiation, on late rectal toxicity. In the acute treatment setting no significant differences in reducing the incidence of acute proctitis symptoms in patients receiving misoprostol, however, significantly more rectal bleeding had been reported., Patients and Methods: A total of 100 patients who had undergone radiotherapy for prostate cancer had been entered into this phase III randomized, placebo-controlled, double-blind study with misoprostol or placebo suppositories. The toxicity was evaluated yearly after cessation of irradiation by the RTOG/LENT-SOMA scale., Results: The median follow-up was 50 months. 20 patients suffered from grade 1, four patients from grade 2 as well, and three patients only from grade 2 toxicity. Frequency, bleeding and urgency were the most commonly reported symptoms. In keeping with other studies and clinical experience, the symptoms peaked within the first 2 years with a median for grade 1 of 13 months and for grade 2 of 15 months. The presence of acute toxicity grade 2 showed a correlation with the development of any late toxicity (p = 0.03). Any acute rectal bleeding was significant correlated with any late rectal bleeding (p = 0.017)., Conclusion: Misoprostol given as once-daily suppository for prevention of acute radiation-induced proctitis does neither influence the incidence and severity of radiation-induced acute nor late rectal toxicity. Misoprostol has no negative impact on the incidence and severity of late rectal bleeding, in contrast to acute rectal bleeding. The routine clinical use of misoprostol suppositories cannot be recommended.

Purpose: To evaluate prospectively the effect of sodium butyrate enemas on the treatment of acute and the potential influence on late radiation-induced proctitis., Patients and Methods: 31 patients had been treated with sodium butyrate enemas for radiation-induced acute grade II proctitis which had developed after 40 Gy in median. During irradiation the toxicity was evaluated weekly by the Common Toxicity Criteria (CTC) and subsequently yearly by the RTOG (Radiation Therapy Oncology Group) and LENT-SOMA scale., Results: 23 of 31 patients (74%) experienced a decrease of CTC grade within 8 days on median. A statistical significant difference between the incidence and the severity of proctitis before start of treatment with sodium butyrate enemas compared to 14 days later and compared to the end of irradiation treatment course, respectively, was found. The median follow-up was 50 months. Twenty patients were recorded as suffering from no late proctitis symptom. Eleven patients suffered from grade I and 2 of these patients from grade II toxicity, too. No correlation was seen between the efficacy of butyrate enemas on acute proctitis and prevention or development of late toxicity, respectively., Conclusion: Sodium butyrate enemas are effective in the treatment of acute radiation-induced proctitis in patients with prostate cancer but have no impact on the incidence and severity of late proctitis.

Background and Purpose: Chronic radiation proctitis/enteritis is a relevant complication of pelvic irradiation, which is still mainly treated by supportive measures only. There is some evidence that the combined treatment with pentoxifylline and tocopherol might alter the pathogenesis of radiation-induced fibrosis. In a retrospective analysis the clinical benefit of the treatment with pentoxifylline/tocopherol on radiation-induced proctitis/enteritis was evaluated, compared to supportive care only., Patients and Methods: Of 30 patients with radiation-induced proctitis/enteritis grade I-II according to the RTOG/EORTC toxicity criteria, 21 were treated with pentoxifylline and tocopherol. Depending on physician's decision nine patients received symptomatic treatment only., Results: With pentoxifylline/tocopherol treatment 15/21 patients (71%) experienced a relief of their symptoms. A reduction from grade I/II to grade 0 toxicity was observed in seven and from grade II to grade I toxicity in eight patients. No improvement was seen in six patients. The median time to improvement with pentoxifylline and tocopherol treatment was 28 weeks. In three of nine patients who were treated supportively only, deterioration of symptoms occurred. Three patients experienced no amelioration, and three patients with grade I toxicity experienced a spontaneous relief of their symptoms (33%)., Conclusion: The combination treatment with pentoxifylline and tocopherol seems to have a benefit in patients with grade I-II radiation-induced proctitis/enteritis. The optimal schedule of treatment duration is not yet clear. From the observations made in this study it is assumed the treatment should be given for 6-12 months at least. A prospective phase II study should be undertaken to evaluate optimal treatment duration.

Background: Chemotherapy-induced mucositis can be related to a decrease in oral neutrophils. We tested the relationship between radiation-induced mucositis and oral neutrophil counts., Patients and Methods: Oral neutrophil counts were obtained for ten patients with head and neck cancer who received radiotherapy of the pharynx and oral cavity. Four patients received additional chemotherapy (5-FU, Mitomycin). Counts were obtained before and during treatment; four healthy volunteers were included in the study as well. For evaluation, a quantitative mouth rinse assay, including neutrophil-staining with acridin-orange, was applied., Results: We observed large inter-individual variations with respect to neutrophil counts for patients and control persons (Table 1). During treatment (irradiation or chemoirradiation), large intra-individual variations were seen additionally (Figure 1). We found a correlation between neutrophil counts and clinical reaction grade. Neutrophil counts increased with increasing mucositis (Figure 2). This increase was more pronounced for patients treated with chemoirradiation compared to radiation alone. Treatment breaks at weekends had no clear influence on neutrophil counts., Conclusions: We observed a weak correlation between neutrophil counts and clinical reaction grade. However, the variations in neutrophil counts are too large to utilize this parameter as a surrogate for clinical mucositis grading. The assumption that a decrease in oral neutrophils is associated with radiation-induced mucositis was clearly negated.

Background and Purpose: The intention of this prospective study is to assess the influence of different patient positionings and the use of belly boards on the coverage of the uterus by standard radiation fields., Material and Methods: In 21 women with carcinoma of the uterine cervix magnetic resonance imaging (MRI) scans in prone patient position with and without belly board and computed tomography (CT) scans in supine position were analysed after superimposing standard pelvic box fields. Further, all patients underwent a second MRI field control in prone position with belly board to detect intraindividual variations in the uterus position during treatment., Results: Standard portals did not completely cover the uterus in supine position in 7/21 (33%), in prone position with belly board in 7/21 (33%) and without belly board in 5/21 (24%). Insufficient uterine coverage was found only in the anteroposterior direction. The mean distance (+/- standard deviation) between the field borders of the lateral portals and the uterus was in supine position anteriorly 3.4 cm (+/-2.2 cm) and posteriorly 1.8 cm (+/-1.3 cm), in prone position with belly board anteriorly 2.2 cm (+/-2.7 cm) and posteriorly 2.6 cm (+/-1.6 cm), prone without belly board anteriorly 3.3 cm (+/-2.4 cm) and posteriorly 1.9 cm (+/-1.1 cm). The difference was statistically significant between supine and prone position with belly board and between prone position with and without belly board. Repeated MRI controls during therapy showed no significant changes compared to the MRIs at the beginning of therapy., Conclusions: The use of standard radiation fields results in a high percentage of geographical misfits. Three-dimensional treatment planning is a prerequisite for adequate uterus coverage.

Radiotherapy (RT) for head and neck cancer is now guided by cone-beam computed tomography (CBCT). We aim to identify a CBCT radiomic signature predictive of progression to RT. A cohort of 93 patients was split into training (n = 60) and testing (n = 33) sets. A total of 88 features were extracted from the gross tumor volume (GTV) on each CBCT. Receiver operating characteristic (ROC) curves were used to determine the power of each feature at each week of treatment to predict progression to radio(chemo)therapy. Only features with AUC > 0.65 at each week were pre-selected. Absolute differences were calculated between features from each weekly CBCT and baseline CBCT1 images. The smallest detectable change (C = 1.96 × SD, SD being the standard deviation of differences between feature values calculated on CBCT1 and CBCTn) with its confidence interval (95% confidence interval [CI]) was determined for each feature. The features for which the change was larger than C for at least 5% of patients were then selected. A radiomics-based model was built at the time-point that showed the highest AUC and compared with models relying on clinical variables. Seven features had an AUC > 0.65 at each week, and six exhibited a change larger than the predefined CI 95%. After exclusion of inter-correlated features, only one parameter remains, Coarseness. Among clinical variable, only hemoglobin value was significant. AUC for predicting the treatment response were 0.78 (p =.006), 0.85 (p <.001), and 0.99 (p <.001) for clinical, CBCT4-radiomics (Coarseness) and clinical + radiomics based models respectively. The mean AUC of this last model on a 5-fold cross-validation was 0.80 (±0.09). On the testing cohort, the best prediction was given by the combined model (balanced accuracy [BAcc] 0.67 , p <.001). We described a feature selection methodology for delta-radiomics that is able to select reproducible features which are informative due to their change during treatment. A selected delta radiomics feature may improve clinical-based prediction models. [ABSTRACT FROM AUTHOR]

Résumé Cet article passe en revue les grands principes thérapeutiques en matière d’irradiation des cancers de la tête et du cou. La radiothérapie avec modulation d’intensité (RCMI), associée à une chimiothérapie par cisplatine est désormais le standard en situation exclusive hors préservation laryngée. Le cétuximab doit être privilégié en cas de contre-indications aux sels de platine tandis que l’hyperfractionnement peut être évoqué en cas de contre-indication à un traitement concomitant. En situation postopératoire, une chimiothérapie par cisplatine est proposée en cas d’effractions capsulaires et d’atteinte des tranches de section, et peut également être discutée en cas de facteurs d’agressivité histologique. Plusieurs études de désescalade thérapeutique en cas d’infection par les papillomavirus sont en cours. La radiothérapie adaptative, l’immunothérapie, ainsi que l’imagerie pour guider la thérapeutique représentent également des domaines de recherche qui aboutiront certainement à des modifications de prise en charge dans les années à venir. Therapeutic principles of radiation therapy in head and neck carcinomas will be discussed in this review. Intensity-modulated radiotherapy with concomitant cisplatin should be standard. In case of contraindication to chemotherapy, cetuximab is an option, while hyperfractionation should be considered in patients unfit for concomitant treatment. Concomitant chemotherapy should be administered in the presence of extracapsular extensions and positive margins in the postoperative setting. Current research areas such as desescalation in human papillomavirus-positive tumours, adaptive radiotherapy, radiomics and immunotherapy will also be addressed. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the patient positioning accuracy in radiotherapy using a stereo-time of flight (ToF)-camera system. Methods: A system using two ToF cameras was used to scan the surface of the patients in order to position them daily on the treatment couch. The obtained point clouds were registered to (a) detect translations applied to the table (intrafraction motion) and (b) predict the displacement to be applied in order to place the patient in its reference position (interfraction motion). The measures provided by this system were compared to the effectively applied translations. The authors analyzed 150 fractions including lung, pelvis/prostate, and head and neck cancer patients. Results: The authors obtained small absolute errors for displacement detection: 0.8 ± 0.7, 0.8 ± 0.7, and 0.7 ± 0.6 mm along the vertical, longitudinal, and lateral axes, respectively, and 0.8 ± 0.7 mm for the total norm displacement. Lung cancer patients presented the largest errors with a respective mean of 1.1 ± 0.9, 0.9 ± 0.9, and 0.8 ± 0.7 mm. Conclusions: The proposed stereo-ToF system allows for sufficient accuracy and faster patient repositioning in radiotherapy. Its capability to track the complete patient surface in real time could allow, in the future, not only for an accurate positioning but also a real time tracking of any patient intrafraction motion (translation, involuntary, and breathing). [ABSTRACT FROM AUTHOR]

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Abstract: Radiotherapy for bone metastases represents an important part of daily practice in our departments of radiotherapy. Majority of treatments deliver either one fraction (6 to 10Gy) or multifractions mainly using 30Gy in ten fractions. In the past decade, several randomized trials aimed to determine the optimal scheme of radiotherapy in this setting. In the present review, the efficacy of radiotherapy on bone metastases will be evaluated using the following parameters: the partial or complete responses on pain, the reduction of antalgic intake, bone recalcification, and need for reirradiation. Other parameters must also be considered, such as the primary site, number of metastasis, performance status, overall prognosis and side effects of radiotherapy. [Copyright &y& Elsevier]

La démarche de certification de la Haute Autorité de santé constitue un enjeu important pour un établissement de santé et en particulier pour un service de radiothérapie. Elle s'articule autour d'une méthodologie de qualité et de gestion des risques portée par un engagement fort et une implication des professionnels. Le service de radiothérapie du centre hospitalier régional universitaire de Brest est depuis de nombreuses années dans une politique de qualité et de gestion des risques exigeante, rythmée par des inspections de l'Autorité de sûreté nucléaire, mais portée par un engagement fort des responsables du service qui déploient une volonté de maintenir un niveau efficient et performant pour la qualité et la sécurité des soins. The French Higher Health Authority's (Haute Autorité de santé [HAS]) certification process is an important issue for a health care facility and in particular for a radiotherapy department. It is based on a quality-risk management methodology driven by the commitment and involvement of professionals. The radiotherapy department of the university hospital in Brest (France) has been engaged for many years in a demanding quality-risk management policy implementation, subjected to regular inspections by the French Nuclear Safety Authority (Autorité de sûreté nucléaire [ASN]). This implementation is driven by a strong commitment from department managers, who are determined to maintaining an efficient level for care quality and safety. [ABSTRACT FROM AUTHOR]

Over the last decades, the refinement of radiation therapy techniques has been associated with an increasing interest for individualized radiation therapy with the aim of increasing or maintaining tumor control and reducing radiation toxicity. Developments in artificial intelligence (AI), particularly machine learning and deep learning, in imaging sciences, including nuclear medecine, have led to significant enthusiasm for the concept of "rapid learning health system". AI combined with radiomics applied to (18F)-fluorodeoxyglucose positron emission tomography/computed tomography ([18F]-FDG PET/CT) offers a unique opportunity for the development of predictive models that can help stratify each patient's risk and guide treatment decisions for optimal outcomes and quality of life of patients treated with radiation therapy. Here we present an overview of the current contribution of AI and radiomics-based machine learning models applied to (18F)-FDG PET/CT in the management of cancer treated by radiation therapy. [ABSTRACT FROM AUTHOR]

Résumé La radiothérapie conformationnelle avec modulation d’intensité (RCMI) permet une épargne significative en termes de dose aux organes à risque chez les patientes prises en charge pour un cancer gynécologique. Compte tenu des forts gradients de dose autour du volume cible prévisionnel, les variations anatomiques interne des organes pendant le traitement peuvent cependant entraîner un « sous-dosage » du volume cible anatomoclinique et un surdosage des organes à risque. Il est donc important de prendre en compte le mouvement et les déformations des organes pelviens et d’étudier les solutions potentielles apportées par la radiothérapie guidée par l’image. Une revue de la littérature a été effectuée en utilisant les bases de données suivantes : Medline, Embase, la bibliothèque Cochrane, Web of Science, Cinahl et Pubmed. Des stratégies de recherche appropriées aux bases de données ont été élaborées en fonction des termes relatifs à « uterine neoplasms, image-guided radiotherapy, adaptative radiotherapy, organ motion and target volume ». Ces études montrent que le mouvement utérin est principalement influencé par la réplétion vésicale, le mouvement cervical et de la voûte vaginale par la réplétion rectale. Les marges entre le volume cible anatomoclinique et le volume cible prévisionnel basées sur la population sont importantes, entraînant une inclusion inutile des organes à risque dans le volume cible prévisionnel, réduisant les avantages de la RCMI. Cependant, le mouvement des organes pelviens étant spécifique à chaque patiente, des marges de volume cible prévisionnel individualisées et des stratégies de radiothérapie adaptative semblent pouvoir assurer une couverture adéquate du volume cible tout en augmentant l’épargne des organes à risque. Dans cette étude, nous faisons une revue des différentes techniques de radiothérapie guidée par l’image utilisées et les perspectives concernant la radiothérapie adaptative. Abstract Intensity-modulated radiation therapy reduces the dose to organs at risk in patients treated for gynecological malignancies. Given the steep dose gradients around the planning target volume, internal movement of organs during treatment may cause a planning target volume underdosage and organs at risk overdosage in case of systematic error. It is therefore important to take into account the movement of the pelvic organs and to investigate potential solutions provided by image-guided radiotherapy. A review of the literature was carried out using the following databases: Medline, Embase, Cochrane Library, Web of Science, Cinahl and Pubmed. Appropriate search strategies for each database were applied based upon the following terms “uterine neoplasms, image-guided radiotherapy, adaptive radiotherapy, organ motion and target volume”. These studies show that uterine motion is mainly influenced by bladder filling and by cervix and vaginal vault motion due to rectal filling. Population-based clinical target volume–planning target volume margins are large resulting in unnecessary organs at risk inclusion within the planning target volume, reducing the benefits of intensity-modulated radiotherapy. As pelvic organ motion seems to be patient specific, individualised planning target volume margins and adaptive radiotherapy strategies could allow adequate coverage of the planning target volume and increase organs at risk savings. In this study, we review the different techniques of image-guided radiotherapy and the perspective of adaptive radiotherapy. [ABSTRACT FROM AUTHOR]

Abstract: Oxaliplatin is integrated in treatment strategies against a variety of cancers including chemoradiation protocols against gastrointestinal, especially rectal cancers. Solid biological data with respect to radiosensitizing activity of oxaliplatin are still rare. This review is based on in vitro and experimental in vivo data concerning the combination of oxaliplatin and radiation published until July 2007. Taking either cell viability or clonogenic survival as an endpoint all reported on oxaliplatin-induced radiosensitization, and enhancement ratios ranged from 1.1 to 2.2. In vivo, enhanced tumor growth delay after combined oxaliplatin and radiation treatment was also reported. Therefore, oxaliplatin should be considered a potent radiosensitizer, although the mechanisms causing radiosensitizing properties of oxaliplatin have not been studied in detail. Herein, they are discussed with respect to apoptosis induction, p53-related signalling, cell cycle control, and DNA-repair. [Copyright &y& Elsevier]

Mise en place en 2017, la réforme du 3e cycle a modifié l'organisation de l'internat toutes spécialités confondues, et notamment l'oncologie-radiothérapie. L'internat a été scindé en 3 phases : la phase socle, la phase d'approfondissement et la phase de consolidation. Cette dernière, réalisée sous le statut de « docteur junior », créé et défini par le décret n°2018-571 du 3 juillet 2018 et l'arrêté du 16 janvier 2020, est une phase d'autonomie supervisée de l'interne. L'oncologie-radiothérapie est une spécialité singulière, aux activités multiples et complexes, et nécessite des compétences plurielles. Un guide définissant le statut du « docteur Junior » dans cette discipline apparait donc nécessaire afin de rappeler le rôle et les obligations de chaque interne. Celui-ci revêt un caractère consultatif et doit être adapté aux particularités de chaque service. Ce guide vise à aider à la mise en place de la réforme du 3e cycle en oncologie-radiothérapie, et plus particulièrement de la dernière année qu'est la phase de consolidation. Il est voué à évoluer, enrichi des retours d'expérience individuels et collectifs ainsi que du renouvellement permanent de notre spécialité. Introduced in 2017, the reform of the 3rd cycle has modified the organization of the residency in all specialties, and in particular radiation oncology. The residency was thus divided into 3 phases with increasing knowledge and responsibilities. The latter, carried out under the status of "junior doctor", created and defined by decree n°2018-571 of July 3, 2018 and the decree of January 16, 2020, is a phase of supervised autonomy of the resident. Radiotherapy is a singular specialty, with multiple and complex activities, and requires multiple skills. A guide defining the status of the "Junior Doctor" in radiation oncology therefore appears necessary, defining each resident's role and obligations. This guide is of an advisory nature and must be adapted to the particularities of each department. This guide aims to help the implementation of the reform of the 3rd cycle in radiation oncology and especially the final year called the consolidation phase. It is destined to evolve, expanded by individual and collective feedback and the constant renewal of our speciality. [ABSTRACT FROM AUTHOR]

During radiotherapy (RT) for prostate cancer (PCa), interfraction and intrafraction movements can lead to decreased target dose coverage and unnecessary over-exposure of organs at risk. New image-guided RT techniques accuracy allows planning target volume (PTV) margins reduction. We aim to assess the feasibility of a kilovoltage intrafraction monitoring (KIM) to track the prostate during RT. Between November 2017 and April 2018, 44 consecutive patients with PCa were included in an intrafraction prostate motion study using the Truebeam Auto Beam Hold® tracking system (Varian Medical Systems, United State) triggered by gold fiducials localization on kilovoltage (kV) imaging. A 5-mm PTV was considered. A significant gating event (SGE) was defined as the occurrence of an automatic beam interruption requiring patient repositioning following the detection of one fiducial outside a 5-mm target area around the marker during more than 45 seconds. Six patients could not benefit from the KIM because of technical issues (loss of one fiducial marker = 1, hip prosthesis = 4, morbid obesity causing table movements = 1). The mean rate of SGE per patient was 14 ± 19%, and the fraction average delivery time was increased by 146 ± 86 seconds. For a plan of 39 fractions of 2 Gy, the additional radiation dose increased by 0.13 ± 0.09 Gy. The mean rates of SGE were 2% and 18% (P = 0.002) in patients with planned fraction < 90 and > 90 seconds respectively, showing that duration of the session strongly interfered with prostate intrafraction movements. No other significant clinical and technical parameter was correlated with the occurrence of SGE. Automated intrafraction kV imaging can effectively perform autobeam holds due to intrafraction movement of the prostate in the large majority of patients. The additional radiation dose and delivery time are acceptable. This technique may be a cost-effective alternative to electromagnetic transponder guidance. [ABSTRACT FROM AUTHOR]

Résumé Objectif de l’étude L’objectif de cette étude était l’analyse de la délinéation des volumes cibles basée sur une segmentation automatique obtenue à partir de la tomographie par émission de positons au ( 18 F)-fluorodésoxyglucose (FDG) couplée à une scanographie (TEP-scanographie) et son impact dosimétrique par rapport à une délinéation manuelle classique basée sur la scanographie et autres examens diagnostiques dans les tumeurs de l’œsophage traitées par irradiation. Matériels et méthodes Il s’agit d’une étude rétrospective portant sur un ensemble de patients atteints d’un cancer de l’œsophage non traité par irradiation et ayant bénéficié d’une TEP–scanographie au FDG préthérapeutique entre 2009 et 2014. Un total de 58 patients a été inclus. La majorité était atteinte d’un carcinome épidermoïde (84,5 %) et d’une maladie de stade IIIA (37,9 %). L’œsophage moyen était le siège de 44,8 % des lésions. La planification a été réalisée sur la scanographie de la TEP–scanographie. Un premier volume tumoral macroscopique ( gross tumour volume [GTV]) a été délinéé sur la scanographie sans avoir connaissance des résultats de la TEP–scanographie au FDG (GTV CT ). Un second volume a été segmenté automatiquement sur les données de la TEP–scanographie par trois méthodes différentes : utilisation de seuils fixes de standard-uptake value (SUV) absolu de 2,5 (GTV 2,5 ) et relatif de 40 % de la SUV maximale (GTV 40 % ) et d’un seuil adaptatif basé sur le bruit de fond environnant (GTV SBR ). Les volumes cibles ont été comparés en longueurs, volumes et à l’aide de l’indice de conformité. Une dosimétrie à 50 Gy puis 66 Gy avec modulation d’intensité a été réalisée sur les deux volumes afin de comparer les couvertures des volumes cibles prévisionnels ( planning target volume [PTV]) et les doses reçues par les organes à risque. Résultats Le premier volume tumoral macroscopique était significativement plus haut que le GTV SBR (6,4 contre 5,3 cm, p < 0,008). Les doses délivrées aux poumons (volume recevant 20 Gy, dose moyenne), cœur (volume recevant 40 Gy) et moelle (dose maximale) étaient significativement inférieures lorsque la dosimétrie était réalisée sur le PTV SBR . La couverture du PTV SBR était significativement meilleure que celle du PTV CT sur les dosimétries à 50 Gy ( p < 0,0004) et à 66 Gy ( p < 0,0006). Conclusion Il existe un intérêt dosimétrique à l’utilisation de la segmentation automatique basée sur le bruit de fond lors de la planification de la radiothérapie des tumeurs œsophagiennes, avec une diminution de la dose reçue par les organes à risque, tout en permettant une meilleure couverture du volume cible prévisionnel. Cela pourrait permettre une escalade de dose jusqu’à 66 Gy. Purpose To study the impact on radiotherapy planning of an automatically segmented target volume delineation based on ( 18 F)-fluorodeoxy-D-glucose (FDG)-hybrid positron emission tomography–computed tomography (PET-CT) compared to a manually delineation based on computed tomography (CT) in oesophageal carcinoma patients. Methods and materials Fifty-eight patients diagnosed with oesophageal cancer between September 2009 and November 2014 were included. The majority had squamous cell carcinoma (84.5 %), and advanced stage (37.9 % were stade IIIA) and 44.8 % had middle oesophageal lesion. Gross tumour volumes were retrospectively defined based either manually on CT or automatically on coregistered PET/CT images using three different threshold methods: standard-uptake value (SUV) of 2.5, 40 % of maximum intensity and signal-to-background ratio. Target volumes were compared in length, volume and using the index of conformality. Radiotherapy plans to the dose of 50 Gy and 66 Gy using intensity-modulated radiotherapy were generated and compared for both data sets. Planification target volume coverage and doses delivered to organs at risk (heart, lung and spinal cord) were compared. Results The gross tumour volume based manually on CT was significantly longer than that automatically based on signal-to-background ratio (6.4 cm versus 5.3 cm; P < 0.008). Doses to the lungs (V20, D mean ), heart (V40), and spinal cord (D max ) were significantly lower on plans using the PTV SBR . The PTV SBR coverage was statistically better than the PTV CT coverage on both plans. (50 Gy: P < 0.0004 and 66 Gy: P < 0.0006). Conclusion The automatic PET segmentation algorithm based on the signal-to-background ratio method for the delineation of oesophageal tumours is interesting, and results in better target volume coverage and decreased dose to organs at risk. This may allow dose escalation up to 66 Gy to the gross tumour volume. [ABSTRACT FROM AUTHOR]

Résumé Objectif de l’étude Nous avons comparé rétrospectivement, pour des cas de cancer du sein gauche, les doses délivrées au volume cible prévisionnel, au poumon gauche, au cœur et à l’artère coronaire descendante antérieure gauche lors d’une radiothérapie conformationnelle en respiration libre et d’une radiothérapie asservie à la respiration. Patientes et méthodes Seize patientes ont bénéficié d’une scanographie de simulation tridimensionnelle et d’une scanographie quadridimensionnelle réalisée à l’aide d’une ceinture abdominale. Pour chaque patiente, cinq dosimétries ont été générées : respiration libre, inspiration maximale, expiration maximale, et deux plans optimisés résultant de la réduction de 3 mm des limites postérieures tangentiels pour créer un plan d’inspiration maximale optimisée et d’expiration maximale optimisée. Les histogrammes dose–volume du volume cible prévisionnel, du poumon homolatéral, du cœur et de l’artère coronaire descendante antérieure gauche ont été analysés et comparés. Résultats La couverture du volume cible prévisionnel par l’isodose 95 % était similaire quel que soit le plan dosimétrique concerné ( p = 0,49). L’inspiration maximale permettait de délivrer moins de dose que la respiration libre au poumon homolatéral, au cœur et à l’artère coronaire descendante antérieure gauche. L’inspiration maximale optimisée était plus avantageuse que celle non optimisée ( p < 0,05), avec moins de dose au poumon homolatéral, au cœur et à l’artère coronaire descendante antérieure gauche. Comparés à ceux de l’expiration maximale, les résultats obtenus avec l’inspiration maximale étaient similaires pour ce qui concerne la dose reçue par le poumon et l’artère coronaire descendante antérieure gauche, et meilleurs concernant la dose au cœur. Conclusion La radiothérapie asservie à la respiration permettait, tout en conservant la même couverture du volume cible prévisionnel, une réduction de la dose aux organes à risque (poumon gauche, cœur et artère coronaire descendante antérieure gauche) du fait de la diminution des marges autour des volumes cibles. Son utilisation en phase inspiratoire permettait de plus une expansion pulmonaire donc une réduction proportionnelle du volume pulmonaire irradié et éloignait le cœur des faisceaux, ce que ne permettait pas l’expiration, moins avantageuse. Il s’agit d’une option intéressante pour le traitement du cancer du sein gauche. Purpose The purpose of this study was to compare free-breathing radiotherapy, end-expiration gating and end-inspiration gating for left breast cancer, with respect to the target volume coverage and dose to organs at risk. Patients and methods Sixteen patients underwent 3D and 4D simulation CT. For each patient, five dosimetric plans were compared: free breathing, end-inspiration gating, end-expiration gating, and two optimised plans with a 3 mm reduction of the posterior field edge to create optimised end-inspiration and end-expiration plans. Dose–volume parameters, including planning target volume coverage and dose to lung, heart and left anterior descending coronary artery were analysed. Results Planning target volume coverage was adequate and similar in the five dosimetric plans ( P = 0.49). Significant advantage was found for end-inspiration gating in sparing the ipsilateral lung, heart and left anterior descending coronary artery compared to free-breathing 3D radiotherapy. Optimised end-inspiration was even more favourable than end-inspiration gating ( P < 0.05), with less dose delivered to the ipsilateral lung, heart and left anterior descending coronary artery. When compared to end-expiration gating, end-inspiration gating dosimetric outcomes were similar regarding lung and left anterior descending coronary artery doses, but the heart dose was inferior on the end-inspiration gating compared to end-expiration gating. Conclusion Breathing-adapted radiation therapy allowed for dose reduction to organs at risk (left lung, heart and left anterior descending coronary artery), while keeping the same planning target volume coverage. Therefore it can be considered as an interesting option for left breast cancer radiation treatment. [ABSTRACT FROM AUTHOR]

In patients treated with radiotherapy for a locally advanced lung cancer, respect of dose constraints to organs at risks (OARs) insufficiently protects patients from acute pulmonary toxicity (APT), such toxicities being associated with a potential impact on treatment's completion and the patients' quality of life. Dosimetric planning doesn't take into account regional lung functionality. An APT prediction model combining usual dosimetry features with the mean dose (DMean Pmap) received by a voxel-based volume (Pmap) localized in the posterior right lung has been previously developed. A DMean Pmap ≥ 30.3Gy was associated with a higher risk of APT. In the present study, the authors aim to demonstrate the possibility of decreasing the DMean Pmap via a volumetric arc therapy (VMAT)-based adapted planning and evaluate the impact on the risk of APT. Among the 207 patients included in the initial study, only patients who presented with an APT ≥ grade 2 and with a probability of APT (Prob APT) ≥ 8% based on the prediction model were included. Dosimetry planning was optimized with a new constraint (DMean Pmap < 30.3Gy) added to the usual constraints. Initial and optimized treatment plans were compared using the T-test for independent variables and the non-parametric Mann-Whitney U test otherwise, regarding both doses to OARs and PTV (Planning Target Volume) coverage. Conformity and heterogeneity indexes were also compared. Risk of APT was recalculated using the new dosimetric features and the APT prediction model. Dosimetric optimization was considered successful for 27 out of the 44 included patients (61.4%), meaning the dosimetric constraint on the Pmap region was achieved without compromising the PTV coverage (p = 0.61). Optimization significantly decreased median DMean Pmap from 28.8Gy (IC95% 24.2-33.4) to 22.1Gy (IC95% 18.3-26.0). When recomputing the risk of APT using the new dosimetric features, optimization significantly reduced the risk of APT (p < 0.0001) by reclassifying 43.2% (19/44) of the patients. Our approach appears as both easily implementable on a daily basis and efficient at reducing the risk of APT. Regional radiosensitivity should be considered in usual lung dose constraints, opening the possibility of an easily implementable adaptive dosimetry planning. [ABSTRACT FROM AUTHOR]

Abstract: PET imaging is now considered a gold standard tool in clinical oncology, especially for diagnosis purposes. More recent applications such as therapy follow-up or tumor targeting in radiotherapy require a fast, accurate and robust metabolically active tumor volumes delineation on emission images, which cannot be obtained through manual contouring. This clinical need has sprung a large number of methodological developments regarding automatic methods to define tumor volumes on PET images. This paper reviews most of the methodologies that have been recently proposed and discusses their framework and methodological and/or clinical validation. Perspectives regarding the future work to be done are also suggested. [Copyright &y& Elsevier]

Abstract: Inverted papilloma (IP) is a rare nasosinusal benign tumour, with epithelium surface inversion to inside the stroma. Extension to intracranial temporal fossa and middle ear has been reported in few cases in the literature. This involvement may be derived from either direct extension from sinonasal cavity via the Eustachian tube or primary middle ear involvement secondary to metaplastic changes of the middle ear mucosa. Here, we report a case of inverted papilloma in a male patient, with multiple recurrences, middle ear and intracranial involvement into the temporal fossa with posterior development of malignancy. This patient had received multiple surgeries and radiotherapy but despite of that, his disease recurred several times. As a conclusion, inverted papilloma is a benign tumour with an aggressive course, tendency to recurrence and progression to malignancy. Intracranial and temporal fossa involvements are rare and the treatment depends of the symptoms and the severity of the disease. [Copyright &y& Elsevier]

Abstract: Purpose: To describe the clinical results and tolerance of the combined treatment with radiotherapy and cetuximab for locally advanced head and neck cancer. Patients and methods: From August 2006 and October 2010, 36 patients with advanced squamous cell head and neck carcinoma were treated with radiotherapy (70Gy/35 fractions) and cetuximab (400mg/m2 one week before radiotherapy, following by 250mg/m2 once weekly, until week 7 of radiotherapy). Tolerance was evaluated every week. All patients were examined every 3months the first 3years after therapy, and then every year. Results: The median follow-up was 14months. The majority of patients were male (31 out of 36). Mean age was 59years. The tumours sites were: oral cavity (n =8); oropharynx (n =15); hypopharynx (n =5); larynx (n =8). Ninety percent of tumors were T3 or T4, and 45% were N2 or N3. Complete response was seen in 74% of patients, partial response in 17% and no response in 9% of patients. The overall survival was 44.4%. Relapse occurred in six patients. Anaphylactic reaction during the first infusion of cetuximab was observed in one patient. One patient developed severe aplasia after 48Gy and 5weeks of cetuximab, and died of sepsis. Eighty percent of patients presented acne, 16 patients developed a mucositis grade 2–3 and 23 patients a grade 2 skin reaction. Conclusion: The concomitant use of cetuximab and radiotherapy in locally advanced head and neck carcinoma is well tolerated in this group of patients. The results seem comparable to those in the literature. [Copyright &y& Elsevier]

Abstract: Esophageal cancers are highly malignant tumours with often a poor pronostic, except for minimal lesions treated with surgery. Radiation therapy, or combined radiation and chemotherapy is the most used therapeutic modality, alone or before oesophagectomy. The delineation of target volumes is now more accurate owing the possibility to use routinely the new imaging techniques (mainly PET). The aim of this work is to precise the radio-anatomical particularities, the pattern of spread of esophageal cancer and the principles of 3D conformal radiotherapy illustrated with a clinical case. [ABSTRACT FROM AUTHOR]