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Resume Les adenocarcinomes de l’endometre sont au troisieme rang des sites tumoraux chez la femme en France. Au terme du bilan pretherapeutique, 80 % apparaissent confines a l’uterus. La curietherapie a une place importante dans la strategie therapeutique. Le traitement principal reste l’hysterectomie totale extrafaciale avec annexectomie bilaterale et prelevement ganglionnaire sous-veineux iliaque bilateral. Cependant, apres chirurgie seule, le taux de recidive locoregionale est de 4 a 20 %, reduit de 0 a 5 % apres curietherapie postoperatoire du fond vaginal. La curietherapie postoperatoire est realisee le plus souvent en ambulatoire par trois ou quatre fractions, a haut debit de dose. La curietherapie uterovaginale preoperatoire reste adaptee aux tumeurs localisees envahissant le col. Les patientes atteintes de tumeur localisee mais inoperable pour des raisons generales (

Intensity-modulated radiotherapy (IMRT) has proven its dosimetric superiority over conformational radiotherapy for cervix cancers in terms of digestive toxicity. Volumetric modulated arctherapy (VMAT) has shown its dosimetric interest when compared to IMRT with static beams. The purpose of our study was to compare conformational radiotherapy, VMAT and tomotherapy for cervical cancers with para-aortic lymph nodes irradiation.The dosimetric data from ten patients were compared between the three techniques, with collection of the dose received by the planning target volume, kidneys, bowel, rectum, bladder, bone marrow and spinal cord, as well as the complete dose.There was a significant difference in favour of VMAT and tomotherapy when compared with conformational radiotherapy for the organs at risk: intestines (V(20 Gy), V(30 Gy) and V(45 Gy)), rectum (V(30 Gy) and V(45 Gy)), bladder (V(30 Gy) and V(45 Gy)) and kidneys (V(12 Gy), Daverage, V(20 Gy)). Volumes receiving 20, 30 and 45 Gy were significantly higher in conformational radiotherapy than in VMAT and tomotherapy. There was a significant difference in favour of tomotherapy when compared with VMAT for V(12 Gy) in kidneys and V(45 Gy) in the bladder.This study confirms the interest of VMAT and tomotherapy for pelvic and para-aortic lymph nodes irradiation of cervix cancer when compared with conformational radiotherapy. There was little difference between VMAT and tomotherapy, except for kidney sparing, which was better with tomotherapy and thus may be interesting for patients receiving nephrotoxic chemotherapy.

International audience; Since February 2014, it is no longer possible to use low-dose rate 192 iridium wires due to the end of industrial production of IRF1 and IRF2 sources. The Brachytherapy Group of the French society of radiation oncology (GC-SFRO) has recommended switching from iridium wires to after-loading machines. Two types of after-loading machines are currently available, based on the dose rate used: pulsed-dose rate or high-dose rate. In this article, we propose a comparative analysis between pulsed-dose rate and high-dose rate brachytherapy, based on biological, technological, organizational and financial considerations.

In 2014, the production of iridium 192 wires in France ended. Thus brachytherapy departments had to move to high-dose rate and pulsed-dose rate afterloading techniques. Most of them had already made this migration for some indications, based on the habits and investments. The brachytherapy group organised meetings and opened discussions to share the clinical knowledge and answer to the questions raised by this migration. This made it possible to resolve and describe quite all the clinical and technical cases of brachytherapy. The development of high technology included the use of 3D dosimetry and optimisation of dose distribution and fractionation. The teaching policy of new technologies contributes to the improvement of treatment quality. Last but not least, a better reimbursement of brachytherapy is necessary and currently negotiated.

Prostate cancer radiotherapy has evolved from the old 2D technique to conformal, and then to intensity-modulated radiation therapy (IMRT) and stereotactic radiotherapy. At the same time, image-guidance (IGRT) is routinely used. New techniques such as protontherapy or carbontherapy are being developed with the objective of increased efficacy, decreased treatment duration, toxicity or cost. This review summarizes the evidence-based medicine of new technologies in the treatment of prostate cancer.

International audience

Resume Les cancers epidermoides du canal anal sont des tumeurs radio- et chimiosensibles. En quelques decennies, le traitement conservateur de premiere intention a remplace la chirurgie mutilante. La radiotherapie exclusive a haute dose reste le traitement de reference des stades precoces T1–T2 N0 de moins de quatre centimetres. Trois essais de phase III ont demontre le benefice apporte par la chimiotherapie associee a l'irradiation sur le controle local et la survie sans colostomie. La mitomycine C et le 5-Fluoro-uracile etaient delivres pendant les premiere et cinquieme semaines de l'irradiation. L'association concomitante de 5-Fluoro-uracile et cisplatine et la chimiotherapie neoadjuvante ont ete evaluees dans des essais de phase II. Des essais de phase III sont en cours.

Resume Objectif de l'etude Le developpement des techniques endobronchiques permet de lever efficacement une obstruction bronchique. Parmi ces techniques, seule la curietherapie endobronchique de haut debit de dose permet un traitement a visee curative pour des petits cancers bronchiques invasifs. Cette etude analyse les resultats des 33 premiers patients traites a visee curative par cette technique de 1994 a 1997 pour lesquels le recul est superieur a un an. Patients et methodes Trente-sept lesions ont ete traitees avec une technique delivrant le plus souvent 30 Gy calcules a 1 cm du (des) catheter(s), delivres en six fractions et trois a cinq semaines. Tous les patients ont ete meticuleusement selectionnes sur le caractere localise de la tumeur et les contre-indications formelles a un traitement chirurgical. Ils avaient de lourds antecedents pulmonaires ou generaux. Resultats Avec un recul moyen de 14 mois, le taux de controle local endoscopique et histologique etait de 95 % a deux mois et 90 % des tumeurs ont ete controlees. Quatre patients sont decedes de leur cancer et un cinquieme d'une recidive controlaterale. Dix patients sont decedes d'autres causes, dont cinq en relation avec une insuffisance respiratoire preexistante. Le taux de survie globale a deux ans etait de 53 % et celui de survie specifique de 80 %. La tolerance a ete bonne, sans accident aigu. Seules des stenoses bronchiques asymptomatiques decouvertes par la surveillance endoscopique ont ete decrites dans sept cas. Conclusion Sous couvert d'une selection soigneuse des patients et du respect des indications, la curietherapie endobronchique de haut debit de dose est un traitement efficace. Elle comble un vide therapeutique et doit etre proposee pour les petits cancers invasifs chez les patients inoperables.

Resume Introduction Malgre les progres chirurgicaux et la reduction de mortalite operatoire, le pronostic du cancer de l'œsophage reste defavorable. Le but de cette revue est de faire le point sur l'apport des techniques non chirurgicales, y compris palliatives. Actualites et points forts Les cancers de l'œsophage sont sensibles a la chimiotherapie mais, en maladie metastatique, la duree de reponse est courte et la toxicite significative. De ce fait, une chimiotherapie palliative devrait etre realisee preferentiellement dans le cadre d'un essai clinique. Par ailleurs, la chimiotherapie utilisee seule n'a pas fait la preuve de son efficacite en complement de la chirurgie. Pour les cancers inoperables, la radiotherapie a visee curative, lorsqu'elle est utilisee comme seul traitement, s'est averee inferieure a une radio-chimiotherapie. Les donnees concernant la radio-chimiotherapie preoperatoire sont encourageantes, mais les resultats des essais randomises sont discordants. Une reponse complete histologique a la radio-chimiotherapie constitue toutefois un facteur pronostique favorable. Les protheses metalliques expansives sont devenues le traitement palliatif endoscopique de premiere intention du fait de leur facilite d'implantation et d'une morbidite faible. Elles trouvent leurs indications optimales dans le traitement des fistules ou de la dysphagie des cancers du bas œsophage. Perspectives et projets Les taxoides devraient etre evalues par des etudes randomisees de chimiotherapie ou de radio-chimiotherapie. Les progres de la radiotherapie (hyperfractionnement, augmentation de la dose delivree, curietherapie associee) devraient permettre d'ameliorer le controle local et la survie. La question de l'interet d'une eventuelle chirurgie seconde chez les patients repondeurs a la radio-chimiotherapie reste ouverte.

Resume La curietherapie joue un role majeur dans le traitement conservateur des cancers de la cavite buccale. L'analyse de la litterature montre de grandes variations dans les definitions et les taux de complications. Peu de publications fournissent ces details pourtant necessaires pour ces comparaisons. Des mesures prophylactiques, des indications et une technique rigoureuse sont indispensables pour minimiser le risque de complications. Des facteurs de risque lies au traitement ont ete individualises dans des analyses multifactorielles de grandes series utilisant le systeme de Paris: un debit de dose inferieur a 0,5 ou 0,7 Gy/h, un espacement entre les fils de 1,2 a 1,5 cm, une surface traitee inferieure a 12 cm2, une activite lineique inferieure a 1,5 mCi/cm, des manchons de surdosage inferieurs a 1 cm de diametre et l'utilisation d'une gouttiere plombee moulant la mandibule reduisent le risque de complications. Certains facteurs sont egalement lies au patient et a la tumeur. L'apport des nouveaux projecteurs de source utilisables en curietherapie interstitielle (curietherapie puisee) permettant le controle du debit de dose et la correction de certaines inhomogeneites devra etre evalue par des etudes cliniques. Les hauts debits de dose doivent etre proscrits pour les curietherapies interstitielles exclusives. Une classification precise et reproductible doit donc etre utilisee pour decrire les complications tardives et comparer les series dans le but de reduire les sequelles et finalement d'ameliorer la qualite de la vie des patients.

International audience; Preoperative radiochemotherapy followed by total mesorectal excision is the standard of care for T3-T4-N0 or TxN1 rectal cancer. Defining target volumes relies on the patterns of nodal and locoregional failures. The lower limit of the clinical target volume depends also on the type of surgery. Conformational radiotherapy with or without intensity-modulated radiotherapy implies an accurate definition of volumes and inherent margins in the context of mobile organs such as the upper rectum. Tumoral staging recently improved with newer imaging techniques such as MRI with or without USPIO and FDG-PET-CT. The role of PET-CT remains unclear despite encouraging results and MRI is a helpful tool for a reliable delineation of the gross tumour volume. Co-registration of such modalities with the planning CT may particularly guide radiation oncologists through the gross tumour volume delineation. Acute digestive toxicity can be reduced with intensity modulation radiation therapy. Different guidelines and CT-based atlas regarding the target volumes in rectal cancer give the radiation oncologist a lot of ground for reproducible contours.

The planning of irradiation treatments is a task of medical physics, based on the appropriate calculations of a dose distribution from radiation beams, virtually set up on a simulation software. This task is at the centre of the chain of treatment preparation: between the contouring phase and the objective definition, which are specialties of the radiation oncologist, and the joint validation of the treatment plan by the physician and the physicist. Historically, this task has been performed by the medical physicist, but can be delegated to other professionals, especially radiation technologists. The evolution of the techniques and procedures tends to a specialization of the skilled workers toward this new work of dosimetry specialist or treatment planning technician. In this paper, the training, relational and organizational aspects will be described to explain how the delegation of the tasks, in the context of treatment plan preparation between professionals can be set up with the highest level of quality and security for the patient treatment and with the respect of legal obligations and requirements of each profession.

For more than a century, brachytherapy has been a treatment of choice for delivering a high dose in a small volume. However, over the past 15 years, this irradiation technique has stalled. Even so, brachytherapy allows the delivery of the right dose at the right place by dispensing with target volume motion and repositioning. The evolution of brachytherapy can be based on a road-map including at least the following three points: the acquisition of clinical evidence, teaching and valuation of the procedures. The evolution of brachytherapy will be also impacted by technological considerations (end of the production of low dose rate 192 iridium wires). Regarding the evolution toward a personalized treatment, brachytherapy of the future should take its place as a partner of other modern external beam radiation techniques, be performed by experimented actors (physicians, physicists, technicians, etc.) who received adequate training, and be valued in proportion to the delivered medical service.

To evaluate the safety and efficacy of whole breast irradiation with a concomitant boost.This is a retrospective study of 121 patients with node negative T1-T2 breast tumors inferior to 3 cm in diameter, previously treated by conservative surgery without chemotherapy. A dose of 50 Gy was delivered to the whole breast in 2 Gy daily fractions with 5 weekly treatments. A concomitant boost to the lumpectomy site delivered a total of 10 Gy in 1 Gy fractions twice a week. This would result in an equivalent tumour bed dose (assuming an α/β of 4) of approximately 65 Gy in 2 Gy fractions.Over 7 years, 121 patients were treated. The median age was 67 years (range, 46-86 years). Stage distribution was: 115 T1, 6 T2; 116 tumors had positive hormonal receptors, 6 grade SBR3. With a median follow-up of 6 years (range, 1.4-11.4 years), 5-year overall survival was 98.2% (95% confidence interval [CI] 0.95-1), disease-free survival was 100% and local recurrence-free survival 100%. The maximum acute skin toxicity by the end of treatment was grade 2. Cosmetic outcomes were good on the long term. One spontaneous rib fracture was observed 1 year after radiotherapy among 76 patients.The study shows that whole breast radiation therapy with a concomitant boost is safe and effective for selected patients with low risk of relapse, and gives excellent long term results. This protocol represents a good alternative to longer standard whole breast radiation therapy with sequential boost to the lumpectomy bed.

During the last decade, the organization of brachytherapy in France moved to 62 units in 173 radiotherapy centres in 2009. More than 7500 patients were treated in 2009, quite exclusively with curative intent, for 80% in public or associated hospitals. The techniques improved to high tech 3D dosimetry and optimization of the dose distribution. Brachytherapy, despite representing only 5% of the treatments by irradiation, is a reference treatment for several tumors.

Our study focuses on a series of 1344 cases of carcinoma of the oral cavity and oropharynx treated between 1973 and 1992. Brachytherapy was always performed with iridium 192, either alone or in combination with external-beam irradiation or with surgery for the treatment of the primary tumor. For the oral cavity, we studied 565 cases of mobile tongue. The local control and overall survival rates, respectively, at 5 years are as follows: for T1, 92% and 70%; for T2, 62% and 42%; and for T3, 50% and 29%. For the subgroup T1T2NO, there was a better prognosis for treatment by brachytherapy of the primary lesion alone (p < 0.0001). Two hundred seven cases of floor-of-mouth carcinoma have been reported. The T3T4 patients were not considered surgical candidates. The local control and overall survival rates, respectively, at 5 years are as follows: for T1, 97% and 71%; for T2 72% and 42%; and for T3, 51% and 35%. Ninety-seven patients were treated by postoperative brachytherapy. These were patients for whom the margins after surgery were positive or narrow. A technique termed the modified bridge is described for lesions located in the mandible. Carcinomas of the buccal mucosa are rare in our country; only 42 cases were treated in this comparison of two techniques, and the overall survival rate was 48%. Epidermoid carcinomas of the oropharynx have nearly always been treated by a combination of external-beam irradiation and brachytherapy because of the bilateral node risk. Seventy-two patients with epidermoid cancers of the base of the tongue had an overall survival rate of 44%. The tonsil, soft palate, and pillars benefited from the use of the loop technique of brachytherapy combined with external-beam irradiation. Three hundred sixty-one patients were treated. Among these patients were two groups with different prognoses. Patients with tonsil, soft palate, and posterior pillar carcinomas had a local control rate of 84% and an overall survival rate of 57%. Conversely, the anterior pillar and the pharyngoglossal sulcus have a local control rate of only 65% and an overall survival rate of 38%. Statistical analysis revealed the prognostic factors for local control. The complications were classified into four grades: minor (20%), moderate (9%), major (4%), or inducing death (0.2%). The bone complications of grade 2 or 3 are more frequent for the floor of the mouth than for other locations.

Resume La radiotherapie a considerablement evolue en 1 siecle. Apres la revolution amenee par le cobalt au debut des annees 60, cette fin de siecle voit la deuxieme revolution s'installer dans trois domaines en radiotherapie externe. Methodologique, le developpement des programmes d'assurance qualite doit assurer la conformite du traitement realise avec la prescription. Technologique, les developpements recents autorisent la radiotherapie conformationnelle, qui permet d'augmenter sensiblement la dose sans augmenter les effets secondaires. Biologique, la mise au point des tests predictifs permet le choix des modalites adaptees a chaque cas particulier. En curietherapie, l'emploi de sources irradiant a haut debit permet de repondre a des indications jusqu'alors inaccessibles. La curietherapie a debit pulse va permettre une optimisation de la repartition de dose dans des volumes complexes. Dans l'avenir, les indications de radiotherapie curative devraient sensiblement augmenter du fait d'un diagnostic plus precoce et d'une plus grande efficacite des traitements generaux sur la maladie metastatique.

De 1977 a 1991, nous avons traite 361 carcinomes de la region veloamygdalienne, soit par curietherapie seule (18 cas), soit par association d'irradiation externe et de curietherapie (343 patients). Cette derniere etait realisee par une technique speciale de fils d'iridium sous tubes plastiques avec chargement differe. Le point de depart de la tumeur etait dans 128 cas l'amygdale et dans 134 le voile du palais. On denombrait egalement neuf piliers posterieurs, 63 piliers anterieurs et 27 sillons amygdaloglosses. Selon la classification de l'UICC de 1979 [28], on a pu classer les patients en 90 T1, 141 T2, 119 T3, 2T4, 9 Tx avec 230 NO, 93 N1. 9 N2, 20 N3 et 9 Nx. Les resultats a 5 et 10 ans donnent respectivement : 80 % et 75 % pour le controle local (CL) ; 75 % et 70 % pour le controle locoregional ; 53 % et 28 % pour la survie globale ; 63 % et 52 % pour la survie specifique. L'etude univariee montre a 5 ans un meilleur controle local pour les Tl-T2 (87 %) que pour les T3 (67 %) avec un p = 0,00004. Le controle locoregional est meilleur pour les N0 (80 %) que pour les N+ (66 %) avec p = 0,002. Il en est de meme pour la survie globale (59 % contre 42 %, p = 0,002). Par rapport au point de depart tumoral, deux groupes ont pu etre individualises. A l'interieur de chacun de ces deux groupes, le pronostic est identique pour les differentes localisations, ce qui permet de les rassembler. On peut donc distinguer un groupe A qui comprend l'amygdale, le voile du palais et le pilier posterieur. Ce groupe a un meilleur pronostic (controles et survies) que le groupe B (pilier anterieur et sillon amygdaloglosse) (p < 0,002). Les tumeurs propagees a la langue mobile, a la base de langue ou au sillon amygdaloglosse ont un moins bon pronostic que celles sans propagation ou a propagation vers le haut (p < 0,002). L'etude statistique des facteurs radiobiologiques qui peuvent influencer la reparation tissulaire montre qu'il y a moins de recidives si la duree du traitement est inferieure a 55 jours et si l'intervalle entre l'irradiation externe et la curietherapie est inferieur a 20 jours. Une marge de securite suffisante semble egalement necessaire a un bon controle local. Le debit de dose dans les limites utilisees ne semble pas influencer le controle local ni la dose totale delivree a la tumeur, mais ceci n'est pas etonnant puisque les doses les plus elevees sont donnees aux tumeurs qui ont le moins regresse durant l'irradiation externe. L'etude multivariee pour le controle local montre que les elements les plus significatifs sont le T, la localisation tumorale et la duree totale du traitement. Pour les complications (classees en quatre stades), le debit de dose est le facteur le plus significatif.

Out of 332 epidermoid carcinomas of the base of the tongue treated in Centre Alexis Vautrin from 1978 to 1992, 136 received. a treatment with a curative intent. The median age was 58 years, the median follow-up was 57 months. We numbered 55 T1-T2 and 81 N0 or N1. From the therapeutic point of view, the patients were classified into three groups: in group 1 (45 cases), they were treated by external irradiation only (median dose: 71 Gy); in group 2 (72 cases), they were treated by external irradiation and brachytherapy (the mean dose delivered by external irradiation was 50 Gy, and by brachytherapy, the mean dose was 30 Gy with a mean dose rate of 55 cGy/h); in group 3 (19 cases), they were treated by a radiosurgical association, the surgical resection was always mutilating and completed by an external irradiation (55 Gy), 8 patients received an associated barrier brachytherapy. Thirty-nine patients presented a local failure, 50 a locoregional evolution. The rate of local control at 5 years was 19% for group 1, 39% for group 2 and 32% for group 3. The calculation of the equivalent biologic dose in group 1 allows to separate this population into two subgroups whose survival rates are significantly different (at 3 years: 26% and 6%, P = 0.02) and shows the influence of fractionation and treatment time. The actuarial survival at 3 years is 19% for group 1, 55% for group 2 and 45% for group 3, the survival without evolution is 33% for group 1, 66% for group 2 and 72% for group 3. For the whole series, we numbered 18 complications of grade equal or superior to 2 (healing in more than 3 months, or sequelae or death) out of which four bone complication and 14 tissular complications that occurred in a mean delay of 9 months. Because of technical modifications, there have been no grade complications for implantations performed from 1989. The prognosis remains poor for cancers of the base of the tongue. The rates of survival are still low when they are treated by external irradiation only. There seems to exist a slight advantage in favour of the radio-brachytherapy association compared to the radiosurgical association with a lower rate of sequelae and mutilations.

Economic data in the literature for brachytherapy are still sparse and heterogeneous, with few controlled prospective studies and a perspective most often limited to those of the provider (health insurances). Moreover, these observation and conclusions are difficult to generalize in France. The prospective health economic studies performed in France in the framework of a national program to sustain innovative and costly therapies (STIC program) launched by the French cancer national institute are therefore of most importance. With the exception of prostate brachytherapy with permanent seeds, the valorisation of the brachytherapy activity by the French national health insurance does not take into account the degree of complexity and the real costs supported by health institutions (i.e. no specific valorisation for 3D image-based treatment planning and dose optimization and for the use of pulsed dose rate brachytherapy).

Low dose-rate brachytherapy as a boost after concomitant chemoradiation therapy is a standard of care for locally advanced anal carcinoma, providing a rigorous selection taking into account the initial staging and tumor response to external beam radiotherapy. Local control is likely to be superior when the boost is performed with brachytherapy than with external beam radiotherapy. The several steps of the brachytherapy procedure are described. The standard treatment scheme is a concomitant chemoradiation therapy, including 45 Gy (1,8 Gy × 5) pelvic external beam radiotherapy and two courses of 5-fluorouracil and mitomycin-C, followed by a 15 Gy brachytherapy boost with a gap limited to 2 to 3 weeks. Higher irradiation dose for the most advanced cases has not yet demonstrated a therapeutic gain in terms of colostomy free survival. Exclusive brachytherapy for in-situ carcinoma or invasive carcinoma less than 10mm is not recommended due to a high risk of local recurrence. Pulsed dose rate brachytherapy is an alternative to low dose rate brachytherapy (iridium wires) providing the respect of the recommended dose rate (0.5 to 1 Gy/hour). High dose rate brachytherapy is still under evaluation.

With an experience of more than 25 years for the pioneers (and more than 14 years in France), permanent implant brachytherapy using iodine 125 seeds (essentially) is now recognized as a valuable alternative therapy for localized low-risk prostate cancer patients. The possible extension of the indications of exclusive brachytherapy towards selected patients in the intermediate-risk group has now been confirmed by several studies. Moreover, for the other patients in the intermediate-risk group and for the patients in the high-risk group, brachytherapy, as an addition to external radiotherapy, could represent one of the best ways to escalate the dose. Different permanent implant brachytherapy techniques have been proposed; preplanning or real-time procedure, loose or stranded seeds (or both), manual or automatic injection of the seeds. The main point here is the ability to perfectly master the procedure and to comply with the dosimetric constraints, which have been recently redefined by the international societies, such as the GEC-ESTRO group. Mid- and long-term results, which are now available in the literature, indicate relapse-free survival rates of about 90% at 5-10 years, the best results being obtained with satisfactory dosimetric data. Comparative data have shown that the incontinence and impotence rates after brachytherapy seemed to be significantly inferior to what is currently observed after surgery. However, a risk of about 3 to 5% of urinary retention is usually reported after brachytherapy, as well as an irritative urinary syndrome, which may significantly alter the quality of life of the patients, and last several months. In spite of those drawbacks, with excellent long-term results, low rates of incontinence and impotence, and emerging new indications (focal brachytherapy, salvage brachytherapy after localized failure of an external irradiation), permanent implant prostate brachytherapy can be expected to be proposed to an increasing number of patients in the next future.

The main indications of brachytherapy for head and neck cancers are limited tumours of the oral cavity, the oropharynx and the nasopharynx. This technique can be exclusive, associated with external radiotherapy or postoperative. This is also a treatment for second localizations in previously irradiated areas. If low-dose rate brachytherapy is the reference, the pulse dose rate brachytherapy by control of the dose rate and optimisation of the dose distribution is the technique to be preferred. High-dose rate brachytherapy is an option. The major prognosis factors of local control and complications are the use of a leaded protection of the mandible, the intersource spacing (1.2-1.4 cm), the volume treated (30 cm(3), i.e. three loops), the safety margin (5 mm), the dose rate (0.5 Gy/h), the total dose (65 Gy in case of exclusive brachytherapy, 25 Gy in case of a combination of external beam irradiation [50 Gy] and brachytherapy in the oropharyngeal carcinomas, 35 Gy in case of a combination of external beam irradiation [40 Gy] and brachytherapy in the oral cavity carcinomas, 60 Gy in case of a second localization in previous irradiated tissues), the delay between external irradiation and brachytherapy (20 days), the dose per fraction and the treated volume for high-dose rate brachytherapy. Brachytherapy, when possible, is the optimal method of irradiation of head and neck carcinomas with limited volume.

Resume L'etude porte sur 346 carcinomes de la cavite buccale (244 langues mobiles et 102 planchers de bouche) traites par curietherapie seule pour la tumeur primaire. On denombrait 199 T1, 131 T2, 14 T3 et 2 TX NX. Parmi les T1, 36 patients ont eu un evidement ganglionnaire ainsi que 73 T2. La curietherapie a ete realisee selon le systeme de Paris. Les curages du cote lesionnel ont ete 59 fois un grand curage du cou, dans 14 cas un curage conservateur et dans 45 cas un curage sous-maxillaire et sous-mental. Un evidement controlateral associe a ete fait dans 20 cas. Une irradiation complementaire des aires ganglionnaires a ete realisee dans 28 cas. Resultats: pour les T1, le controle local (CL) est a 96%, le controle locoregional (CLR) a 83%, la survie specifique (SS) a 88%, la survie globale (SG) a 73%. Pour les T2, CL 85%, CLR 70%, SS 75%, SG 52%. Pour les T3, CL 64%, CLR 44%, SS 25%, SG 18%. La difference est tres significative entre les T1, T2, T3 ( p cf tableau IV). Les recidives ganglionnaires sont plus frequentes chez les patients sans curage que chez ceux avec curage pour les T1, T2, N0, mais cela n'est significatif que pour les CLR, la SS et la SG entre les patients a ganglions negatifs au curage et ceux a ganglions positifs ( p

No technique can now be used without previously considering the safety of patients, staff and public and risk management. This is the case for brachytherapy. The various aspects of brachytherapy are discussed for both the patient and the staff. For all, the risks must be minimized while achieving a treatment of quality. It is therefore necessary to establish a list as comprehensive as possible regardless of the type of brachytherapy (low, high, pulsed dose-rate). Then, their importance must be assessed with the help of their criticality. Radiation protection of personnel and public must take into account the many existing regulation texts. Four axes have been defined for the risk management for patients: organization, preparation, planning and implementation of treatment. For each axis, a review of risks is presented, as well as administrative, technical and medical dispositions for staff and the public.

To develop an external quality control procedure for CyberKnife(®) beams. This work conducted in Nancy, has included a test protocol initially drawn by the medical physicist of Nancy and Lille in collaboration with Equal-Estro Laboratory.A head and neck anthropomorphic phantom and a water-equivalent homogeneous cubic plastic test-object, so-called "MiniCube", have been used. Powder and solid thermoluminescent dosimeters as well as radiochromic films have been used to perform absolute and relative dose studies, respectively. The comparison between doses calculated by Multiplan treatment planning system and measured doses have been studied in absolute dose. The dose distributions measured with films and treatment planning system calculations have been compared via the gamma function, configured with different tolerance criteria.This work allowed, via solid thermoluminescent dosimeter measurements, verifying the beam reliability with a reproducibility of 1.7 %. The absolute dose measured in the phantom irradiated by the seven participating centres has shown an error inferior to the standard tolerance limits (± 5 %), for most of participating centres. The relative dose measurements performed at Nancy and by the Equal-Estro laboratory allowed defining the most adequate parameters for gamma index (5 %/2mm--with at least 95 % of pixels satisfying acceptability criteria: γ1). These parameters should be independent of the film analysis software.This work allowed defining a dosimetric external quality control for CyberKnife(®) systems, based on a reproducible irradiation plan through measurements performed with thermoluminescent dosimeters and radiochromic films. This protocol should be validated by a new series of measurement and taking into account the lessons of this work.

Treatment technique training needs theoretical and practical knowledge allowing proposing the right treatment for the right patient, but also allowing performing the technical gesture in the best conditions for an optimal result with a maximal security. The evolution of the brachytherapy techniques needs the set up of specific theoretical and practical training sessions. The present article focuses on the importance of the brachytherapy training as well as the different means currently available for the young radiation oncologist community for perfecting their education. National and international trainings are presented. The role of the simulation principle in the frame of brachytherapy is also discussed. Even if brachytherapy is not always an easy technique, its efficacy and its medico-economical impact need to be passed down to motivated students with the implementation of relevant educational means.

Acute and mainly late toxicity is a major concern for radiotherapists. Here, we describe a case of a generalized acute eruption due to radiation, having a superficial and deep perivascular lymphocytic infiltrate with numerous eosinophils found in skin biopsy: the EPPER syndrome (eosinophilic polymorphic pruritic eruption associated with radiotherapy). A patient who had endometrial cancer was treated first by surgery, then radiotherapy developed the day following the end of irradiation a generalized erythematous, pruriginous eruption (pelvis, trunk, lower and upper limbs, neck, face, ears). Different tests with a skin biopsy found a superficial and deep perivascular lymphohistiocytic infiltrate with many eosinophils, confirming an EPPER syndrome. The description of the syndrome was first published in 1999 by Rueda et al. (1999) [1]. Later on, there have only been a few case reports on this subject. This syndrome can be encountered in many cancers, but more frequently in cervix and breast carcinomas and can occur up to nine and a half months after radiotherapy. The pathogenic mechanism is unknown. Antihistamines, topical corticosteroids or oral corticosteroids as well as ultraviolet B therapy have been used successfully to treat EPPER syndrome. Some cases of spontaneous resolution are also described. EPPER syndrome is probably largely underestimated due to its polymorphic characteristics, its occurrence sometimes late after radiotherapy. Its knowledge is essential to inform and treat patients correctly.

International audience; Because of the low mortality rates associated with prostate cancer, treatments long-term adverse effects constitute an important parameter in the management of patients. In particular, androgen deprivation has been shown to be linked to several metabolic disorders which are already frequent in men after age 60, such as weight and fat gain, insulin resistance likely to evolve into diabetes, and dyslipidemia. So far no consensus guidelines have been published regarding the screening and treatment of metabolic disorders in men with prostate cancer. It is essential to detect and manage these metabolic disorders, all the more so as they seem to be associated with an increased aggressiveness of prostate cancer. Here we report the development of a new questionnaire, which might contribute to the systematic management, and potentially the screening and treatment or the prevention of these metabolic disorders in patients with prostate cancer. In accordance with recent reviews and on the basis of experience, our French board of experts also recommends systematic screening and selective treatment for diabetes, regular follow-up of fasting glucose rates, lipid profile and blood pressure in all patients under long-term androgen deprivation treatment, as well as lifestyle changes (practice of exercise, nutritional habits).

Intensity modulated radiotherapy (IMRT) allows a better coverage of the target volume and a better saving of organs at risk with a decrease of toxicity in head and neck cancers. It requires more human labor and materials compared to conformational radiotherapy. If they are insufficient, a selection of the patients receiving IMRT may be necessary, raising an ethical problem.We collected the motives guiding the choice of the technique of radiotherapy for head and neck cancers during a month of physicists' shortage.Nineteen patients received IMRT and eight conformational radiotherapy. Conformational irradiation was chosen in palliative and postsurgery treatments, to reduce delay, in laryngeal tumors and re-irradiation. IMRT was preferred for complex target volumes and the localizations at risk of important xerostomia following conformational radiotherapy. These choices were confronted with the bioethics criteria of Beauchamp and Childress. The beneficence justified the use of IMRT or conformational radiotherapy depending on the circumstances. The non-maleficence attempted to decrease the toxicity with IMRT. Justice was questioned by the selection. The autonomy of patients was not totally respected in the choice.To help in the choice of the patients receiving an IMRT in a crisis situation, we proposed a hierarchical organization of selection criteria: complex volumes close to critical organs at risk, localization with high risk of xerostomia, long life expectancy and postoperative delay constraints.

Many clinical studies have showed the key role of radiotherapy in anticancer treatment strategy. Radiations are delivered alone or in combination with systemic therapies. In recent years, the main goal of all clinical developments has focused on improving clinical benefit, with an increased tumour control and a higher normal tissue protection. This research was designed to reduce local recurrences, to increase recurrence-free or overall survival and to decrease acute and late effects. Technological and biological evolutions (or revolutions) accompanied clinicians to improve clinical benefit, namely with strong progress in radiology and better understanding of radiobiology, particularly at the molecular level. Differences in tumour and normal tissues radiosensitivity are nowadays integrated in daily clinical practice of radiation oncologists. The current report details the last 5-year developments of clinical and translational research in radiation oncology, especially the role of French teams in the development of personalized treatment.

Concurrent radiochemotherapy is the standard treatment for locally advanced cervical cancer. This treatment is responsible for bowel and hematologic toxicities. The use of intensity-modulated radiotherapy (IMRT), in static beams, allows a decrease of this toxicity. The technique of RapidArc(®) IMRT could lower the dose delivered to the organs at risk and improve the homogeneity of the planning target volume coverage, while decreasing the processing time.For 20 patients, treatment plans performed with IMRT and RapidArc(®) were compared. The target volumes were: the clinical target volume (gross tumour volume, uterus, upper third of the vagina, the hypogastric, iliac and presacral nodal regions), and the planning target volume (clinical target volume+1cm). The delineated organs at risk were: rectum, bladder, bowel and bone marrow. The dose was 45 Gy in 25 fractions. IMRT were delivered with five beams and RapidArc(®) with two arcs. The comparisons were made by the non-parametric test of Wilcoxon.Medium coverage of the planning target volume was better with RapidArc(®) (P=0.01). It was also better regarding the sparing of bowel (P=0.01) and IMRT was better regarding the sparing of bladder (P=0.01) and rectum (P=0.05). The total volume receiving 20 Gy was less important with RapidArc(®) (P0.001). RapidArc(®) allowed to decrease the treatment time (3 versus 12 minutes with IMRT) and the number of monitor units (MU) (376.5 versus 962.2, on average, P=0.0001).The technique of RapidArc(®) seems to obtain better dosimetric results compared to RCMI, with fewer MU, and a significant decrease in treatment time.

Surgical resection remains the standard treatment for patients with resectable retroperitoneal sarcomas. The aim of this study was to retrospectively analyse the outcomes of patients with primary retroperitoneal sarcoma.We analysed data of 50 patients with primary retroperitoneal sarcoma who underwent curative-intent resection from 1975 to 2008. External beam radiotherapy and chemotherapy were delivered postoperatively. Demographics, surgical, pathological variables and chemo/radiation therapy were analysed as prognosis factors.There were 22 males and 28 females (mean age 54 ± 13 years). Surgery required visceral resections in 30 patients. There were 16 leiomyosarcomas, 25 liposarcomas and eight other sub-types. Twenty-one patients had clear surgical margins. Twenty-eight patients received postoperative external beam radiotherapy (median 45 Gy) and 15 received chemotherapy. At the end of the follow-up (median 55 months), local recurrence occurred in 39% (n=14) among R0/R1 resection group (n=36). Postoperative external beam radiotherapy tends to increase the time of local recurrence from surgery (27 vs. 13 months, P=0.05). The overall survival rates were 81%, 55% and 46% at 1, 3 and 5 years, respectively. Although R0 resection (P=0.01), well tumour differentiation (P=0.004) and postoperative external beam radiotherapy (P=0.02) significantly influenced overall survival in univariate analysis, only R0 resection was an independent prognostic factor in a multivariate analysis.We confirm the pre-eminence of radical surgery with negative margins as major prognostic factor and the benefit of postoperative radiotherapy.

Anal canal carcinoma are highly curable by irradiation, combined with chemotherapy in locally advanced disease, with preservation of sphincter function. The clinical target volume for the nodes is extended, often including the inguinal nodes, which is not usual for other pelvic tumours. Acute and late effects are correlated with the volume and dose delivered to organs at risk, i. e. small bowel, bladder and increased by concomitant chemotherapy. Intensity modulated irradiation (IMRT) makes it possible to optimize the dose distribution in this "complex U shaped" volume, while maintaining the dose distribution for the target volumes. The conversion from conformal irradiation to IMRT necessitates good knowledge of the definition and skills to delineate target volumes and organs at risk, including new volumes needed to optimize the dose distribution. Dosimetric and clinical benefits of IMRT are described, based on early descriptions and evidence-based publication. The growing development of IMRT in anal canal radiotherapy must be encouraged, and long-term benefits should be soon published. Radiation oncologists should precisely learn IMRT recommendations before starting the technique, and evaluate its early and late results for adverse effects, but also for long-term tumour control.

This review describes the ballistic quality assurance for stereotactic intracranial irradiation treatments delivered with Gamma Knife® either dedicated or adapted medical linear accelerators. Specific and periodic controls should be performed in order to check the mechanical stability for both irradiation and collimation systems. If this step remains under the responsibility of the medical physicist, it should be done in agreement with the manufacturer's technical support. At this time, there are no recent published guidelines. With technological developments, both frequency and accuracy should be assessed in each institution according to the treatment mode: single versus hypofractionnated dose, circular collimator versus micro-multileaf collimators. In addition, "end-to-end" techniques are mandatory to find the origin of potential discrepancies and to estimate the global ballistic accuracy of the delivered treatment. Indeed, they include frames, non-invasive immobilization devices, localizers, multimodal imaging for delineation and in-room positioning imaging systems. The final precision that could be reasonably achieved is more or less 1mm.

We previously presented a systematic and structured approach to acquire an accurate functional model of the patient's process in radiotherapy. This approach relied on new functional structuring patterns, derived from system engineering and knowledge engineering. Additionally, we propose a complementary methodical process for the dysfunctional analysis of the obtained functional model.The procedure is based on joint implementation of two qualitative methods named "Failure modes and effects analysis" (FMEA) and "Hazard and operability" (HazOp).All the technical, the human and the organizational dimensions of the patient's process are pooled in a unique, exhaustive and detailed dysfunctional analysis. The application of this systematic approach within a particular institution can precisely identify the risks incurred by patients in care, but also highlight the logical sequence between precursor events and incidents.The dysfunctional analysis presented in this document will be used for the development still in process of quantified risk models.

This document presents a systematic and structured approach for functional modeling for risk analysis in radiotherapy, aiming to reconcile the need, on one hand, for a method that can be applied generally and, on the other hand, for a method that provides a highly precise model.The approach relies on new functional structuring patterns and flux analysis, derived from system engineering and knowledge engineering.The method affords strong support for the development of detailed models of the patient's process through a department of radiotherapy. Lack of structure of the actual process in a particular department may be easily identified leading to the development of specific procedures for the improvement of security.Modeling approach derived from engineering may be used for functional modeling for risk analysis in radiotherapy.

Le cancer du canal anal est une tumeur rare. Il est decouvert a la suite de symptomes rectaux tels que douleur, saignement, trouble de la defecation ou masse perceptible. Le diagnostic repose sur la biopsie pour analyse histologique. L’histologie la plus frequente est le carcinome epidermoide. Le bilan d’extension associe un examen clinique complet avec anuscopie, un scanner abdomino-pelvien, une echo-endoscopie anale, une radiographie pulmonaire et eventuellement une IRM. Le morpho-PET, de plus en plus utilise, semble apporter son interet dans le diagnostic, mais surtout dans le bilan d’extension, la recherche d’une recidive et permettrait d’ameliorer les volumes d’irradiation. Le traitement de reference du carcinome epidermoide du canal anal est conservateur par irradiation, associee a une chimiotherapie en casde tumeur localement avancee. Le traitement chirurgical non conservateur par amputation abdomino-perineale est reserve aux echecs therapeutiques, aux recidives locales ou aux grosses tumeurs ayant detruit le sphincter. La surveillance post-therapeutique doit etre rapprochee durant les cinq premieres annees afin de depister une recidive accessible a un traitement curatif de rattrapage.

This study aimed at analyzing the evolution and type of recurrence in patients treated for stage I endometrial carcinomas, in order to define the respective roles of adjuvant radiotherapy and brachytherapy.This monocentric retrospective study was conducted at Centre Alexis-Vautrin, Nancy, France, between January 1995 and December 2000 on all the patients surgically treated for an endometrial cancer, and then treated with high dose rate vaginal brachytherapy. The brachytherapy was delivered in two or three fractions of 7 Gy at 5 mm from the applicator.In the good prognosis group, the specific and overall survivals at 5 years were respectively 96.5 and 94.2% with no local recurrence demonstrated. In the intermediate prognostic group, the specific and overall survivals at 5 years were respectively 88 and 85%, with six locoregional recurrences observed among those who did not undergo lymphadenectomy; the overall survival at 5 years was significantly decreased in the absence of external radiation. In the group of poor prognosis (stages II and III), the specific survival at 5 years was respectively 72.8 and 67 %, and the overall survival at 5 years 66.7 and 56.4%.Results for local control and survival as well as for tolerance were good. So we have decided to deliver high rate brachytherapy for all intermediate or poor prognosis patients and we have abandoned pelvic radiotherapy for good prognosis tumours (stages IA: no myometrium invasion with grade 3 and50% of myometrium invasion with grades 1 and 2), whatever the lymph nodes surgery they had. We now propose pelvic radiotherapy only for intermediate prognosis tumours (such as IA50% of myometrium invasion with grade 3 and IB stages), if patients did not have any lymphatic surgery, or for bad prognosis tumours.

The anal canal is regarded as an organ at risk more often in pelvis radiation, but also in brachytherapy. Acute or chronic complications depend on its different components and are different from the anal margin or the rectum. The toxicity scale can be the NCI CT C version 3, completed by the tardive toxicity SOMALENT scale. The mean dose and maximal dose are recognized as predictors of complications. The maximum recommended dose despite the paucity of literature is 55 Gy.