Search

In this article, we report the case of a newborn who presented a life-threatening hepatomegaly with respiratory distress at 12 days of life, complicating a metastatic neuroblastoma. Low-dose liver radiotherapy was performed in emergency in order to decompress. Chemotherapy has also been delivered due to a tumoral relapse 1 month after radiotherapy. After a follow-up of 20 years, this young woman is still in complete remission, with no long-term sequelae.

Resume Objectif Evaluer la tomotherapie helicoidale du mesotheliome pleural malin et l’impact des faibles doses sur la toxicite pulmonaire et œsophagienne. Patients et methodes De juin 2007 a mai 2011, 29 patients atteints de mesotheliome pleural malin ont recu une la tomotherapie helicoidale adjuvante. L’âge median etait de 63 ans (34–72). Histologiquement, 83 % des patients etaient atteints d’un mesotheliome pleural malin epithelioide. Cliniquement, 45 % des tumeurs etaient classees T3 et 55 % N0. Quatre-vingt-six pour cent des patients ont ete operes par pleuropneumonectomie extrapleurale et 35 % ont recu une chimiotherapie neoadjuvante par sels de platine et pemetrexed. La dose mediane dans la cavite de pneumonectomie etait de 50 Gy en 25 fractions de 2 Gy. Resultats Le suivi moyen etait de 2,3 ans apres le diagnostic. Les probabilites de survie globale etaient respectivement de 65 et 36 % a un et deux ans. La duree mediane de survie a partir du diagnostic etait de 18 mois. Les volumes pulmonaires medians recevant 2, 5, 10, 13, 15 et 20 Gy (V2, V5, V10, V13, V15 et V20) etaient respectivement de 100, 98, 52, 36, 19 et 5 %. La mediane de la dose moyenne au poumon restant etait de 11 Gy. Deux patients sont decedes de complications pulmonaires, trois ont souffert d’une pneumopathie de grade 3, tandis qu’une toxicite œsophagienne de grade 3–4 a ete observee chez trois. Aucun impact significatif des caracteristiques cliniques et des parametres dosimetriques releves n’a ete retrouve sur la toxicite pulmonaire, cependant un V10 de 50 % ou plus, un V15 de15 % et ou plus une dose moyenne au poumon restant de 10 Gy ou plus auraient une tendance a etre predictifs de toxicite pulmonaire ( p p = 0,03), ainsi que les faibles doses pulmonaires : V5, V10 et V13 ( p Conclusion La tomotherapie helicoidale est une technique prometteuse dans la prise en charge multimodale des mesotheliomes pleuraux malins. Les faibles doses recues par le poumon controlateral semblent etre cependant le facteur limitant. Il serait interessant de les comparer a celles delivrees par d’autres techniques comme l’arctherapie volumetrique modulee.

Resume Le nombre de patients atteints d’obesite est en augmentation en France depuis deux decennies, avec des consequences sur l’incidence de nombreux cancers. L’obesite a un impact sur la prise en charge des cancers par radiotherapie, du fait des contraintes materielles, techniques et dosimetriques qu’elle implique, ainsi que sur la toxicite aigue et tardive, le controle local et la survie des patients.

Resume Objectifs Evaluation du traitement postoperatoire par electrons ou irradiation interstitielle de bas debit de dose par iridium 192 des cicatrices cheloides. Patients et methodes De 1994 a 2010, 95 patients atteints de 142 cicatrices cheloides ont ete traites par irradiation postoperatoire immediate dans notre institut et retrospectivement revus : 116 cicatrices ont ete traitees par electrons et 26 par iridium 192. Resultats Les cicatrices cheloides traitees par electrons siegeaient sur l’oreille pour 88 (76 %), le thorax pour 14 (12 %), le cou pour neuf (8 %) et les membres pour cinq (4 %). La taille mediane des lesions etait de 3 cm (extremes 0,5–18). Dans 96,5 % des cas, une dose de 15 Gy a ete delivree en cinq fractions de 3 Gy. Le suivi median etait de 70 mois (7–161). Les taux de controle local a deux et cinq ans etaient respectivement de 69 % (intervalle de confiance a 95 % [IC95 %] : 59–76 %) et de 55 % (IC95 % : 45–64 %). Les cicatrices cheloides traitees par iridium 192 siegeaient au niveau du cou pour trois (11 %), l’oreille pour huit (32 %), l’abdomen pour trois (11 %), le thorax pour deux (8 %), les membres pour dix (38 %). La taille mediane des lesions etait de 6,6 cm (1,7–28). La dose mediane delivree etait de 20 Gy (15–20,69) a 5 mm de la source. Le suivi median etait de 113 mois (21–219), les taux de controle local a deux et cinq ans etaient respectivement de 84,6 % (IC95 % : 64–94 %) et 73,5 % (IC95 % : 49–87 %). Dans les deux groupes, la toxicite se limitait a une epitheliite moderee transitoire. Notamment, aucun cas de cancer radio-induit n’a ete releve jusqu’a present. Le taux de controle local n’etait pas significativement different entre les deux traitements (p = 0,0991) mais il existe une tendance en faveur de l’iridium 192 car le taux de rechute a deux ans etait la moitie de celui avec les electrons (15,4 contre 31,3 %). Conclusion La curietherapie semble donner un meilleur taux de controle local que l’electrontherapie, elle peut donc etre proposee en premiere intention. Cependant, l’electrontherapie est une alternative interessante en cas de difficulte a realiser la curietherapie. Il existe probablement un effet dose : d’apres la litterature, une dose d’au moins 25 a 30 Gy doit etre proposee.

See an invited perspective on this article on page 1043.This multicenter phase II study investigated a selective radiotherapy dose increase to tumor areas with significant

Purpose To determine the patterns of locoregional failure (LRF) in patients with locally advanced non-small cell lung cancer treated with definitive radiotherapy (RT). Patients and methods One hundred and fifty-four patients from the Gating 2006 prospective randomized trial were treated with conformal RT with or without respiratory motion management. For patients with a LRF as first event, treatment planning with simulation CT, pre-treatment 18FDG PET-CT and post-treatment images demonstrating recurrence were registered and analyzed. Measurable LRF was contoured (rGTV) and classified as in-field, marginal, or out-of-field. Results Median follow-up was 27.8 months. Forty-eight patients presented with LRF. One-year and 2-year locoregional disease-free survival rates were 77% (95% CI 70–83) and 72% (95% CI 64–79) respectively. 79% of the patients with LRF as first event relapsed within the RT field (55% isolated), 30% had marginal LRF component. Isolated out-of-field failure occurred in only 3% of all patients. The regions of highest FDG-uptake on pre-treatment PET-CT were located within the recurrence in 91% of patients with in-field LRF. Conclusion In-field failure was the most common pattern of failure. Escalated dose RT with high-dose fractions guided by PET parameters warrants further investigation.

Purpose Bilateral pulmonary radiotherapy in children and young adults aims to reduce the recurrence of lung metastases. The radiation field includes liver tissue, which is sensitive to even low radiation doses. We investigated the feasibility of respiratory gating radiotherapy using voluntary deep inspiration breath hold and its toxicity in these patients. Patients and method A retrospective clinical review was conducted for all patients who had undergone bilateral pulmonary radiotherapy, with or without deep inspiration breath hold, treated in our institution between October 1999 and May 2012. A dosimetric study was conducted on seven consecutive children using 4D-scan data on free-breathing and a SpiroDyn’RX-system-scan on deep inspiration breath hold. A radiation treatment of 20 Gy was simulated. Results Concerning the clinical study, seven patients of mean age 11.9 years (range: 4.9–21.1 years) were treated with free-breathing and ten patients of mean age 15.6 years (range: 8.6–19.7 years) were treated with deep inspiration breath hold for mainly Ewing sarcoma and nephroblastoma. Within six months of radiotherapy, all patients experienced mild liver toxicity (grade 1 or 2 altered levels of alanine/aspartate aminotransferase [n = 8 of 9] or cholestasis [n = 1 of 9]), which resolved completely with no difference between deep inspiration breath hold and free-breathing technique. Over a median follow-up of 2.6 years (range: 0.1–9.3 years), four patients died from disease progression (mean 1.5 years post-radiotherapy [range: 1.1–1.6 years]) and three experienced grade III–V lung toxicity. Concerning the dosimetric study, the irradiated liver volume was significantly lower with deep inspiration breath hold than free-breathing, for each isodose (V5: 73.80% versus 86.74%, P Conclusions The dosimetric data of respiratory-gated bilateral pulmonary radiotherapy showed a significantly spare of normal liver tissue. Clinical data showed that this technique is feasible even in young children. However, no liver toxicity difference between deep inspiration breath hold and free-breathing was shown.

Purpose To evaluate toxicity and early disease outcome among patients treated for cervical cancer with extended-field helical tomotherapy to the para-aortic nodes. Patients and methods Thirty-eight patients (International Federation of Gynecology and Obstetrics [FIGO] stage IB2–IVA) from four institutions received extended-field helical tomotherapy and were retrospectively evaluated. All had nodal disease. Para-aortic lymph nodes were involved in 31 patients. Patients were assessed for toxicity using version 4 of the National Cancer Institute's common terminology criteria for adverse events. Survival curves were plotted using Kaplan-Meier estimates. Results All patients underwent radiation to the tumor region (median dose: 45 Gy; range: 44–66 Gy), pelvic lymph nodes and para-aortic lymph nodes (median dose: 45 Gy; range: 44–60 Gy). The median dose to positive lymph nodes was 55 Gy (range: 45–65 Gy). All received platinum-based chemotherapy (31 concurrently). The median follow-up was 15 months. Acute toxicity events observed included one patient with grade 5 febrile neutropenia, 11 patients (29%) with grade 3 hematologic complications. Grades 3–4 gastrointestinal and genitourinary toxicities occurred in six (16%) and four (11%) patients, respectively. Three patients had grade 3 pelvic pain (8%). The 6- and 18-month overall survival rates were 94.7 and 63.9%, respectively. The 18-month locoregional control, disease-free survival, and late grade 3 toxicity rates were 60.2, 43.3 and 7.3%, respectively. Conclusion Extended-field helical tomotherapy was associated with low rates of acute gastrointestinal and genitourinary toxicities with early survival and locoregional control similar to other published series.

Hypofractionated stereotactic radiation therapy (HSRT) for vertebral metastases gives good results in terms of local control but increases the risk of fracture in the treated volume. Preclinical and clinical studies have shown that zoledronate not only reduces the risk of fracture and stimulates osteoclastic remodeling but also increases the immune response and radiosensitivity. This study aimed to evaluate the tolerability and effectiveness of zoledronate in association with radiation therapy.We conducted a multicenter phase 1 study that combined HSRT (3 × 9 Gy) and zoledronate in patients with vertebral metastasis (NCT01219790). The principal objective was the absence of spinal cord adverse reactions at 1 year. The secondary objectives were acute tolerability, the presentation of a bone event, local tumor control, pain control, progression-free survival, and overall survival.Thirty patients (25 male, 5 female), median age 66 years, who were followed up for a median period of 19.2 months, received treatment for 49 vertebral metastases. A grade 3 acute mucosal adverse event occurred in 1 patient during the treatment and in 2 more at 1 month. No late neurologic adverse events were reported at 1 year. The mean pain scores diminished significantly at 1 month (1.35; P=.0125) and 3 months (0.77; P.0001) compared with pain scores at study entry (2.49). Vertebral collapse in the irradiated zone occurred in 1 (2%) treated vertebra. Control of local disease was achieved in 94% of irradiated patients (3 local recurrences).The combination of zoledronate and HSRT in the treatment of vertebral metastasis is well tolerated and seems to reduce the rate of vertebral collapse, effectively relieve pain, and achieve good local tumor control with no late neurologic adverse effects.

Objectif de l’etude La chimioradiotherapie est le traitement de reference des cancers bronchiques non a petites cellules localement evolue, mais le resultat de ce traitement reste mediocre. L’etude RTEP5 (programme hospitalier de recherche clinique [PHRC] de 2011) propose d’augmenter la dose de radiotherapie chez les patients atteints de tumeur hypoxique d’apres la TEP-scanographie au fluoromisonidazole (F-miso). Materiel et methode Chaque patient eligible a beneficie d’une TEP-scanographie pretherapeutique au fluorodesoxyglucose (FDG) afin de definir le volume metabolique et F-miso afin de confirmer le caractere et le volume hypoxiques ; ces examens ont egalement ete realises a 42 Gy dans le cadre d’etudes ancillaires. Les patients chez qui la TEP au F-miso etaient positives et ont beneficie d’une augmentation de dose au sein du volume hypoxique sans limite de dose du boost selon les contraintes pulmonaire (V20 [volume recevant 20 Gy] inferieur a 30 %) et medullaire (dose maximale, Dmax, inferieure a 45 Gy). Resultats Sur 79 pre-inclus, 54 patients etaient definitivement inclus dans l’etude, dont 34 avec une TEP-scanographie au F-miso positive. La fixation sur la TEP au FDG et le volume metabolique etaient significativement plus importants dans le groupe hypoxique ( Standard Uptake Value maximale [SUVmax] de 14,5 ; volume fixant le FDG de 55,4 cm 3 ) que dans le groupe non hypoxique (SUVmax de 10 ; volume fixant le de FDG a 27,3 cm 3 ) ( p = 0,021 ; p = 0,026). Sur les 34 patients eligibles a une augmentation de dose, 24 ont pu en beneficier (dose moyenne de 77,1 Gy [70 a 86 Gy]). Il n’a pas ete mis en evidence de difference de toxicite tant aigue que tardive entre le bras ayant beneficie d’un boost et les patients non hypoxiques (66 Gy). Il s’agit de la plus importante etude clinique proposant de moduler la dose de radiotherapie des cancers bronchiques selon les donnees de l’hypoxie definie par TEP. Conclusion Cette etude demontre : – que les-tumeurs fixant le F-miso sont plus volumineuses et plus hypermetaboliques que les tumeurs ne fixant pas le F-miso ; – la faisabilite d’augmenter la dose de radiotherapie chez les patients traites pour un cancer bronchique non a petites cellules au sein d’une population et d’un volume selectionne par la TEP au F-miso sans augmentation de la toxicite.

Purpose The ACCORD 12 trial investigated the value of two different preoperative chemoradiotherapy (CT-RT) regimens in T3-4 Nx M0 resectable rectal cancer. Clinical results are reported after follow-up of 3 years. Patients and Methods Between November 2005 and July 2008, a total of 598 patients were randomly assigned to preoperative CT-RT with CAP45 (45-Gy RT for 5 weeks with concurrent capecitabine) or CAPOX50 (50-Gy RT for 5 weeks with concurrent capecitabine and oxaliplatin). Total mesorectal excision was planned 6 weeks after CT-RT. The primary end point was sterilization of the operative specimen, which was achieved in 13.9% versus 19.2% of patients, respectively (P = .09). Clinical results were analyzed for all randomly assigned patients according to the intention-to-treat principle. Results At 3 years, there was no significant difference between CAP45 and CAPOX50 (cumulative incidence of local recurrence, 6.1% v 4.4%; overall survival, 87.6% v 88.3%; disease-free survival, 67.9% v 72.7%). Grade 3 to 4 toxicity was reported in four patients in the CAP45 group and in two patients in the CAPOX50 group. Bowel continence, erectile dysfunction, and social life disturbance were not different between groups. In multivariate analysis, the sterilization rate (Dworak score) of the operative specimen was the main significant prognostic factor (hazard ratio, 0.32; 95% CI, 0.21 to 0.50). Conclusion At 3 years, no significant difference in clinical outcome was achieved with the intensified CAPOX regimen. When compared with other recent randomized trials, these results indicate that concurrent administration of oxaliplatin and RT is not recommended.

Resume Objectif Comparaison dosimetrique de deux modalites d’irradiation des cancers bronchiques non a petites cellules localement evolues inoperables : la radiotherapie conformationnelle et la radiotherapie avec modulation d’intensite rotationnelle (Volumetric Modulated Arc Therapy : VMAT). Patients et methodes Chez dix patients atteints de cancer bronchique non a petites cellules dont le traitement etait une chimioradiotherapie, deux plans de traitement ont ete calcules : l’un pour une radiotherapie conformationnelle et l’autre pour une radiotherapie avec modulation d’intensite rotationnelle (RapidArc™). Les doses delivrees dans le volume cible previsionnel (PTV), les organes a risque et le corps (contours externes) ainsi que les indices de conformation et d’homogeneite ont ete compares. Resultats Avec une dose delivree dans le volume cible previsionnel (doses moyenne, maximale et minimale, et indice d’homogeneite) comparable ente la radiotherapie avec modulation d’intensite rotationnelle et la radiotherapie conformationnelle, l’indice de conformation etait nettement superieur avec la radiotherapie avec modulation d’intensite rotationnelle (0,89 ± 0,07) qu’en radiotherapie conformationnelle (0,55 ± 0,07), soit une augmentation de 60 % (p = 0,002). La radiotherapie avec modulation d’intensite rotationnelle permettait une meilleure protection pulmonaire : en radiotherapie conformationnelle et en radiotherapie avec modulation d’intensite rotationnelle, les doses moyennes etaient respectivement de 14,1 ± 5,2 Gy et de 12,2 ± 4,5 Gy, le volume recevant au moins 30 Gy (V30) de 20 ± 8 % et de 14 ± 5 %, et le volume recevant au moins 20 Gy (V20) de 24 ± 11 % et de 20 ± 10 % (p = 0,002). Lorsque l’on etudiait les doses recues dans le corps, la dose moyenne etait significativement plus basse de 9 % avec la radiotherapie avec modulation d’intensite rotationnelle qu’avec la radiotherapie conformationnelle (p = 0,004), le volume recevant 5 Gy (V) augmente de 13 % (p = 0,004), les volumes recevant 10 et 15 Gy (V10 et le V15) non statistiquement differents. A partir de 20 Gy, le volume de corps irradie etait significativement plus grand avec la radiotherapie conformationnelle qu’avec la radiotherapie avec modulation d’intensite rotationnelle. La difference relative augmentait avec la dose : de 10 % a 20 Gy (p = 0,014) jusqu’a 39 % a 62,7 Gy (p = 0,002). Conclusion Par rapport a la radiotherapie conformationnelle, la radiotherapie avec modulation d’intensite rotationnelle augmentait de 60 % la conformation. La dose moyenne et les doses a partir de 20 Gy delivrees aux poumons et au corps etaient significativement reduites.

Resume Objectifs L’objectif principal de l’etude economique etait de mesurer de facon prospective et randomisee les surcouts d’une frequence quotidienne par comparaison a une frequence hebdomadaire des controles de positionnement du patient dans le cadre d’une radiotherapie guidee par l’image ( image-guided radiotherapy [IGRT]) de cancers de la prostate, en prenant en compte les differentes modalites d’imagerie tridimensionnelle : tomographie conique ( cone beam computed tomography [CBCT]) et implants de grains d’or (reperes fiduciels). Un objectif secondaire etait d’evaluer les surcouts des modalites d’une imagerie tridimensionnelle par comparaison a une modalite « bidimensionnelle » par « imagerie portale » pour le controle de positionnement. Patients et methodes Une etude medicoeconomique multicentrique prospective et randomisee a ete realisee afin de comparer differentes frequences de controle de positionnement lors d’une radiotherapie guidee par l’image prostatique. Un groupe temoin prospectif avec imagerie de controle de positionnement par imagerie portale a ete constitue pour comparer les modalites trdimensionnelles (radiotherapie guidee par l’image) et bidimensionnelles de l’imagerie. L’evaluation economique a porte sur les couts directs de la radiotherapie en adoptant le point de vue de l’hopital, avec une technique de microcosting portant sur parametres pouvant induire des differences de couts des strategies evaluees. Resultats L’analyse economique a porte sur 241 patients inclus entre 2007 et 2011 dans sept centres, dont 183 dans l’etude randomisee (128 avec la tomographie conique et 55 avec les reperes fiduciels) et 58 dans le groupe temoin. Le surcout moyen par patient du controle quotidien par rapport au controle hebdomadaire etait de : 847 € (tomographie conique) ou 179 € (reperes fiduciels). Par comparaison a l’imagerie portale, le surcout moyen par patient etait respectivement de 1392 € (tomographie conique) et 997 € (reperes fiduciels) et de 545 € (tomographie conique) et 818 € (reperes fiduciels) pour des strategies de controle respectivement quotidienne et hebdomadaire. Conclusion Une strategie de controle quotidien du positionnement et la mise en œuvre de controles tridimensionnels pour la radiotherapie guidee par l’image de cancers de la prostate, induisent un surcout significatif par rapport a des controles hebdomadaires et une imagerie portale. L’evaluation medicale a plus long terme permettra d’evaluer le ratio cout/efficacite de ces modalites innovantes.

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.

Since the previous special issue of Cancer Radiotherapie dedicated to radiosurgery in 1998, many important technological and computer developments have improved external beam radiotherapy treatment device performances. Whereas the Gamma Knife(®) was the gold standard for intracranial radiosurgery, new linear accelerator developments have led to new possibilities for the clinicians. This article describes quickly the different devices available for cranial radiosurgery or fractionated stereotactic radiotherapy.

The aim of this article was the study of the successive steps permitting the prescription of dose in stereotactic intracranial radiotherapy, which includes radiosurgery and fractionated stereotactic radiotherapy. The successive steps studied are: the choice of stereotactic intracranial radiotherapy among the therapeutic options, based on curative or palliative treatment intent, then the selection of lesions according to size/volume, pathological type and their number permitting the choice between radiosurgery or fractionated stereotactic radiotherapy, which have the same methodological basis. Clinical experience has determined the level of dose to treat the lesions and limit the irradiation of healthy adjacent tissues and organs at risk structures. The last step is the optimization of the different parameters to obtain a safe compromise between the lesion dose and healthy adjacent structures. Study of dose-volume histograms, coverage indices and 3D imaging permit the optimization of irradiation. For lesions close to or included in a critical area, the prescribed dose is planned using the inverse planification method. Implementation of the successively described steps is mandatory to insure the prescription of an optimized dose. The whole procedure is based on the delineation of the lesion and adjacent healthy tissues. There are sometimes difficulties to assess the delineation and the volume of the target, however improvement of local control rates and reduction of secondary effects are the proof that the totality of the successive procedures are progressively improved. In practice, stereotactic intracranial radiotherapy is a continually improved treatment method, which constantly benefits from improvements in the choice of indications, imaging, techniques of irradiation, planification/optimization methodology and irradiation technique and from data collected from prolonged follow-up.

Purpose There is a scarce clinical experience about adjuvant helical tomotherapy (HT) in patients affected by malignant pleural mesothelioma (MPM) even though it appears as a useful technique to treat complex volume as the pleural cavity, and seems to have better dose distribution than the “classic” intensity modulated radiotherapy (IMRT). Methods and materials Twenty-four patients received adjuvant radiotherapy (RT) by HT from August 1st, 2007 to December 1st, 2009 at Curie Institute (Paris) and Rene Gauducheau Cancer Center (Nantes). Thirteen patients had neoadjuvant chemotherapy. Extrapleural pleuropneumonectomy (EPP) was done in 23 patients. Median dose to PTV was 50 Gy [48.7–55.9 Gy] (2 Gy/fraction). Acute and long term toxicities, disease free survival (DFS), overall survival (OS) and relapses are presented. Results Average follow up after RT was 7 months. The disease was staged mostly as T2–T3, N1–N2. Nineteen patients had epithelial type histology. Most patients tolerated radiotherapy with grade 1–2 side effects: redness of the skin, light cough or dyspnea, fatigue, nausea and odynophagia, mild increase of the post-operative thoracic pain. Grade 3 pneumonitis was suspected in 2 patients. Two grade 5 pneumonitis were also suspected. Eleven patients had a follow up of more than 6 months and no long term side effects related with HT were noted. At 24 months, 51.8% of patients were free of disease. Thirty percent of patients relapsed, with 2 patients presenting local relapses. Two patients died from recurrence. Conclusion With limited follow up, HT has comparable toxicity to those observed with traditional IMRT. Higher radiation dose and good coverage results in excellent local control.

The pooled 2-year clinical experience using three tomotherapy units installed in France in 2007 is presented. Treatment indications and protocols were devised for each disease site and were the result of a consensus. A total of 642 patients were treated for central nervous system, head and neck, thoracic, abdominal, and pelvic tumors. Overall, grade 3, 4, and 5 acute toxicity was 10.7%, 0.3%, and 0.2%, respectively. Grade 3 chronic toxicity was 1.2%. There was no grade 4 or 5 chronic toxicity. The use of tomotherapy in a broad clinical practice is safe, and acute and chronic toxicity both are acceptable for all anatomical locations.

Resume Introduction Malgre son interet theorique, peu de donnees concernent le traitement du mesotheliome pleural malin (MPM) par la tomotherapie helicoidale (TH). Patients et methodes Quatorze patients atteints de MPM ont recu un traitement adjuvant par TH a l’institut Curie et au centre Rene-Gauducheau depuis le 1/08/2007. Tous les patients ont eu une pleuro-pneumonectomie extrapleurale (PPEP). La dose mediane dans la cavite de pneumonectomie etait de 50 Gy (48–54 Gy) tandis que les zones a haut risque ont recu concomitamment 57 Gy (54–69 Gy). Resultats Le suivi median etait de 12,6 mois apres la TH. Sept patients ont recu une chimiotherapie neoadjuvante par platine et pemetrexed. Huit patients etaient T3 et cinq patients etaient N1-2. La TH a ete majoritairement bien toleree. Deux patients suspects de pneumopathie radique sont neanmoins decedes. Parmi les 12 patients ayant survecus, six ont recidive : deux recidives locales et metastatiques, quatre metastatiques uniquement. Trois patients sont decedes de leur recidive. La survie mediane a partir du diagnostic etait de 18,4 mois. Une courbe d’apprentissage a ete observee dans l’optimisation des parametres dosimetriques. Conclusion La TH est une technique fiable, plutot bien toleree et efficace, pour traiter les patients atteints de MPM apres PPEP.

Resume Avec environ 1 500 nouveaux cas par an en France, le lymphome de Hodgkin ne represente que 10 a 15 % des lymphomes et 0,5 a 1 % des nouveaux cas de cancers. La prise en charge de cette lymphopathie a connu de profondes evolutions conceptuelles avec le temps, permettant actuellement d’obtenir une guerison dans 75 a 80 % des cas tous stades confondus, et dans plus de 90 % des cas de formes localisees. Si initialement le traitement consistait quel que soit le stade en une irradiation extensive (lymphoide totale ou sub-totale) exclusive, la place de la radiotherapie dans la prise en charge des lymphomes de Hodgkin a evolue avec le temps, et reste aujourd’hui encore une des pierres angulaires du traitement. Elle s’integre desormais dans le cadre de traitements associant chimiotherapie (s) puis irradiation pour les lymphomes de Hodgkin localises, et reste une alternative therapeutique dans toutes les situations (de rechute et/ou de maladie d’emblee disseminee) ou se pose la problematique d’accroitre le taux de controle tumoral locoregional. Malgre l’apport indeniable de la radiotherapie dans le controle de la maladie, les effets secondaires tardifs des traitements ne sont pas negligeables. Le suivi a long terme des patients traites est indispensable compte tenu principalement d’un risque accru de morbidite et de mortalite d’origine cardio-vasculaire, et de second cancer. Il est important de rappeler qu’encore aujourd’hui l’irradiation de type « Involved Field » reste la technique de reference, meme si on assiste actuellement a l’emergence de nouveaux types d’irradiations visant a reduire les volumes irradies pour tenter de limiter les risques de complications radio-induites tardives. L’objectif de cet article est de preciser les particularites (epidemiologiques, radio-anatomiques et pronostiques) de ce type de tumeur, ainsi que les modalites pratiques de l’irradiation (illustrees par un cas clinique) lorsqu’une indication de radiotherapie est posee.

Resume Avec environ 10 000 nouveaux cas par an en France, les lymphomes malins non hodgkiniens representent l’hemopathie maligne la plus frequente et 5 a 10 % des nouveaux cas de cancer. Les lymphomes malins non hodgkiniens constituent un ensemble heterogene de lymphopathies, regroupant des entites aux caracteristiques epidemiologiques, evolutives et pronostiques tres differentes. Il existe plusieurs classifications des lymphomes malins non hodgkiniens mais sur le plan pratique, on individualise des lymphomes agressifs dont le lymphome B diffus a grandes cellules (qui est le lymphome le plus frequent), et les lymphomes indolents dont le lymphome folliculaire et les lymphomes de MALT ( Mucosa-associated lymphoid tissue ). La place de la radiotherapie dans la prise en charge des lymphomes malins non hodgkiniens varie selon le sous-type precis de lymphome, mais elle est devenue de plus en plus limitee avec le temps. Generalement, elle ne trouve des indications a titre curatif que dans des situations de lymphomes malins non hodgkiniens localises, soit associee a de la chimiotherapie dans le cadre d’un traitement combine comme pour la prise en charge des lymphomes B diffus a grandes cellules, soit comme traitement exclusif, notamment dans les rares situations de lymphomes folliculaires localises. Par ailleurs, les lymphocytes etant des cellules extremement radiosensibles, la radiotherapie conserve d’excellentes indications a but palliatif dans de volumineuses masses tumorales symptomatiques, et ce, quel que soit le sous-type de lymphome malin non hodgkinien. Il est important de rappeler qu’encore aujourd’hui l’irradiation de type « Involved Field » reste la technique de reference pour le traitement des lymphomes malins non hodgkiniens ganglionnaires, meme si on assiste actuellement a l’emergence de nouveaux types d’irradiations visant a reduire les volumes irradies pour tenter de limiter les risques de complications radio-induites tardives. L’objectif de cet article est de preciser les particularites (epidemiologiques, radio-anatomiques et pronostiques) des differents lymphomes malins non hodgkiniens (a l’exception des lymphomes cerebraux), ainsi que les modalites pratiques de l’irradiation (illustrees par des cas cliniques) lorsqu’une indication de radiotherapie est posee dans le cadre de leur prise en charge.

Purpose To determine prospectively intermediate-term toxicity and quality of life (QoL) of prostate cancer patients after intensity-modulated radiotherapy (IMRT). Patients and Methods Fifty-five patients with localized prostate adenocarcinoma were treated by IMRT (76 Gy). Physicians scored acute and late toxicity using the Common Terminology Criteria for Adverse Events version 3.0. Patients assessed general and prostate-specific QoL before IMRT (baseline) and at 2, 6, and 18 months using European Organization for Research and Treatment of Cancer questionnaires QLQ-C30(+3) and QLQ-PR25. Results Median age was 73 years (range, 54–80 years). Risk categories were 18% low risk, 60% intermediate risk, and 22% high risk; 45% of patients received hormonal therapy (median duration, 6 months). The incidence of urinary and bowel toxicity immediately after IMRT was, respectively, 38% and 13% (Grade 2) and 2% and none (Grade 3); at 18 months it was 15% and 11% (Grade 2) and none (Grade 3). Significant worsening of QoL was reported at 2 months with regard to fatigue (+11.31, p = 1.10 −7 ), urinary symptoms (+9.07, p = 3.10 −11 ), dyspnea (+7.27, p = 0.008), and emotional (−7.02, p = 0.002), social (−6.36, p = 0.003), cognitive (−4.85, p = 0.004), and physical (−3.39, p = 0.007) functioning. Only fatigue (+5.86, p = 0.003) and urinary symptoms (+5.86, p = 0.0004) had not improved by 6 months. By 18 months all QoL scores except those for dyspnea (+8.02, p = 0.01) and treatment-related symptoms (+4.24, p = 0.01) had returned to baseline. These adverse effects were exacerbated by hormonal therapy. Conclusion High-dose IMRT with accurate positioning induces only a temporary worsening of QoL.

Helical tomotherapy is an innovative device combining with the same linac on board-imaging and IMRT facilities. The first national French evaluations, supported by National Institut of Cancer (INCa) are presented. Dosimetric characteristics as quality of homogeneity, cut-off outside target volumes allow IMRT treatments for large and complex volumes and a good organ at risk sparing. First comparative dosimetric studies are discussed.

Resume Devant les progres technologiques et la multiplication des plans de traitement, disposer d’outils pour evaluer et comparer la dose aux organes a risque est devenu indispensable. Entre plusieurs options assurant la meme couverture tumorale, le choix se fera en faveur de celui qui epargne au mieux les organes a risque. Les outils d’evaluation doivent rendre compte des effets aigus et tardifs de radiotherapie tout en etant d’utilisation simple. L’evaluation de la dose aux organes a risque repose aujourd’hui essentiellement sur les histogrammes dose–volume, les indices conformationnels et la dose integrale. Cependant, aussi precise que soit l’evaluation de la dose, de nombreuses questions subsistent quant a la toxicite de la radiotherapie. Le choix therapeutique entre un plan de traitement delivrant une faible dose dans un grand volume et un plan de traitement delivrant une dose relativement plus elevee dans un petit volume n’est pas a ce jour bien etabli. Le suivi clinique a long terme des patients, avec une evaluation prospective des effets secondaires reste imperatif.

Purpose Neoadjuvant chemoradiotherapy is considered a standard approach for T3-4 M0 rectal cancer. In this situation, we compared neoadjuvant radiotherapy plus capecitabine with dose-intensified radiotherapy plus capecitabine and oxaliplatin. Patients and Methods We randomly assigned patients to receive 5 weeks of treatment with radiotherapy 45 Gy/25 fractions with concurrent capecitabine 800 mg/m2 twice daily 5 days per week (Cap 45) or radiotherapy 50 Gy/25 fractions with capecitabine 800 mg/m2 twice daily 5 days per week and oxaliplatin 50 mg/m2 once weekly (Capox 50). The primary end point was complete sterilization of the operative specimen (ypCR). Results Five hundred ninety-eight patients were randomly assigned to receive Cap 45 (n = 299) or Capox 50 (n = 299). More preoperative grade 3 to 4 toxicity occurred in the Capox 50 group (25 v 1%; P < .001). Surgery was performed in 98% of patients in both groups. There were no differences between groups in the rate of conservative surgery (75%) or postoperative deaths at 60 days (0.3%). The ypCR rate was 13.9% with Cap 45 and 19.2% with Capox 50 (P = .09). When ypCR was combined with yp few residual cells, the rate was respectively 28.9% with Cap 45 and 39.4% with Capox 50 (P = .008). The rate of positive circumferential rectal margins (between 0 and 2 mm) was 19.3% with Cap 45 and 9.9% with Capox 50 (P = .02). Conclusion The benefit of oxaliplatin was not demonstrated and this drug should not be used with concurrent irradiation. Cap 50 merits investigation for T3-4 rectal cancers.

OBJECTIVE: The purpose of this study was to determine the characteristics of early second breast cancer (SBC) among survivors of childhood and young adult malignancy treated with irradiation. METHODS: We conducted a multicenter retrospective study of women who presented with breast cancer aged 50 years or younger in nine French centers. RESULTS: 121 patients and 141 SBC were analyzed (invasive = 130; non-invasive = 11). The mean age at first cancer diagnosis was 15 years and at initial SBC diagnosis was 38 years. Bilateral disease before the age of 51 years was diagnosed in 16% of the females. The majority of SBC were invasive carcinomas (92%). Among the invasive carcinomas, 39% had a histoprognostic score of III, 3.1% overexpressed HER2 and 29% were triple negative. The proportion of triple negative phenotype SBC was higher in patients older at first cancer diagnosis [RR = 1.2, 95% CI (1.1–1.3)]. 94% of triple negative SBCs developed in breast tissue which had received >20 Gy. CONCLUSION: We found a high proportion of aggressive SBC following thoracic radiotherapy in childhood or early adulthood. ADVANCES IN KNOWLEDGE: SBC screening is recommended by scientific societies for these child/young–adulthood cancer survivors in the same way as the one for high risk women because of constitutional mutations. Our results support these recommendations, not only because of a similar cumulative risk, but also because of the aggressive histological characteristics.

Resume Introduction L’objectif de cet article est de rapporter l’experience acquise au centre de lutte contre le cancer Nantes-Atlantique de la radiotherapie guidee par l’image a travers l’utilisation de trois dispositifs d’imagerie de repositionnement, l’ExacTrac® (BrainLAB™), l’OBI-CBCT (Varian™) et le MVCT (Tomotherapy Inc™), dans le cadre de la prise en charge de patients traites par irradiation externe pour un cancer de la prostate. Materiel et methodes Pour chacun des systemes presentes, la technique d’irradiation a ete decrite, ainsi que le protocole d’imagerie associe. Une etude sur les decalages effectues a chaque session d’imagerie a ete menee. Avec le systeme ExacTrac®, une comparaison a ete faite selon que les decalages realises quotidiennement etaient calcules sur les structures anatomiques ou sur les positions d’implants radio-opaques intraprostatiques pour huit patients. De plus, en considerant les decalages moyens sur toute la duree d’un traitement, l’impact dosimetrique des decalages a ete estime. Pour le systeme OBI-CBCT, deux modalites d’imagerie ont ete utilisees, soit deux images orthogonales de basse energie (kV–kV), soit une tomographie conique (CBCT). Jusqu’a present, quelle que soit la modalite, le recalage a toujours ete effectue sur les reperes osseux. Les decalages appliques ont ete compares pour 26 patients. Enfin, pour la tomographie conique de haute energie (MVCT), une imagerie quotidienne a ete systematiquement realisee pour tous les patients. La valeur moyenne des decalages releves apres cinq seances a ete calculee. Pour le reste des seances, pour 12 patients, l’ecart a cette valeur a ete calcule pour montrer la pertinence ou non d’une imagerie quotidienne. Resultats et conclusion Ce travail a permis de rapporter l’integration des dispositifs de repositionnement dans le service de radiotherapie. Il montre egalement les perspectives offertes par ces differents systemes. Ils autorisent au minimum d’assurer un repositionnement quotidien, et ils laissent entrevoir la future possibilite de realiser des radiotherapies guidees par la dose.

Resume Objectif de l’etude Malgre une augmentation recente du nombre des internes en oncologie–radiotherapie ces dix dernieres annees, l’evolution globale de la demographie des oncologues radiotherapeutes reste tres inferieure aux besoins lies aux departs a la retraite et a l’evolution de la discipline. Materiel et methodes Lors des cours nationaux annuels organises par la Societe francaise des jeunes radiotherapeutes oncologues (SFJRO), la Societe francaise de radiotherapie oncologique (SFRO) et le College national des enseignants de cancerologie (Cnec) et soutenus par l’Institut national du cancer (Inca), differentes enquetes ont ete realisees. Resultats Depuis 2002, le nombre total des internes en formation dans l’option oncologie–radiotherapie a augmente regulierement (50, 75, 103 et 109 internes respectivement en 2000, 2005, 2007 et 2008). Il y a legerement plus de femmes que d’hommes (51,5 % contre 48,5 %). L’enseignement a ete evalue a l’aide d’une echelle visuelle analogique et le score etait de 56 pour la formation pratique et 61 pour la formation theorique. Les internes ont pu beneficier d’autres types de formation (analyse de cas cliniques, seances de bibliographie) dans certaines universites. L’analyse des motivations du choix de la specialite oncologie–radiotherapie, a montre un interet commun a la fois pour la pratique medicale et les aspects techniques. Les notions d’innovation, de technologie, d’imagerie et de recherche apparaissaient aussi clairement. Seize internes finissent leur formation fin 2008, 42 en 2009 et 27 en 2010. Presque tous les internes pensent qu’un « post-internat » est necessaire pour completer la formation en tant que chef de clinique – assistant (CCA). Cependant, seuls 36 postes de CCA sont disponibles en France, soit la moitie des besoins. Seulement 21 internes sur 104 sont assures d’avoir un poste de CCA et la disponibilite de ce type de poste reste incertaine pour les autres. Conclusions Malgre des creations recentes de postes de CCA dans le cadre du plan cancer, de dix a 20 postes supplementaires sont necessaires pour que tous les internes puissent y acceder et qu’ils beneficient d’une formation de qualite dans cette discipline transversale, medicale et technique.

After a request for proposal initiated by National Institute against cancer (INCa) in 2005, three French centers in France started tomotherapy in the first semester of 2007. A national policy of evaluation was performed to study the feasibility of this innovative technique and to compare the interest of helicoidal tomotherapy with other modalities of conformal therapy. Common protocols have been designed to facilitate this evaluation. Description of dose, IMRT levels and constraints are achieved according to each selected indication as: sarcoma, head and neck tumors, lung cancer, mesothelioma, bone metastases, anal carcinoma and craniospinal irradiation.

The use of heavy particles in the treatment of cancer is increasing remarkably, whether with external radiation or using a vector such as an antibody in radioimmunotherapy. Recent pre-clinical and clinical developments of alpha-radioimmunotherapy have provided more interesting information in parallel of the use of high Linear Energy Transfer (LET) external irradiation. This review aims at presenting recent advances of this therapeutic approach, and at detailing the biological specificities of this kind of radiation.

La principale caracteristique de la tomotherapie helicoidale est de realiser des traitements en radiotherapie conformation nelle avec modulation d’intensite sur un mode helicoidal grace au deplacement de la table pendant la rotation de l’accelerateur selon le principe du scanner utilise en radiodiagnostic. Le traitement est effectue avec des photons de 6 MV et la degradation de cette energie a 3 MV permet d’acquerir une imagerie pour la dosimetrie et de verifier le positionnement quotidien du patient a chaque seance (technique de la radiotherapie guidee par l’image). Les premieres etudes dosimetriques comparatives laissent entrevoir une certaine superiorite de la tomotherapie helicoidale sur les accelerateurs lineaires classiques. II est cependant necessaire d’attendre les resultats des etudes cliniques en cours pour juger du benefice pour les patients en termes de tolerance et de controle local.

The radiosensitizing properties of gemcitabine in relation to low Linear Energy Transfer (LET) particles (Cobalt 60) and high-LET particles (alpha-RIT 213 Bi-radiolabeled CHX-DTPA-B-B4) were analyzed. Three multiple myeloma cell lines (LP1, RPMI 8226, U266) were irradiated with or without 10nM gemcitabine 24h prior to radiation. Gemcitabine led to radiosensitization of LP1 and U266 cells with low-LET (Radiation Enhancement Ratio: 1.55 and 1.49, respectively) but did not radiosensitize any cell line when combined with high-LET.

Purpose/Objectives To assess feasibility and toxicity of Helical TomoTherapy® for treating anal cancer patients. Methods From 2007 to 2011, 64 patients were consecutively treated with TomoTherapy® in three centres for locally advanced squamous-cell anal carcinoma (T2 > 4 cm or N positive). Prescribed doses were 45 Gy to the pelvis including inguinal nodes and 59.4 Gy to the primary site and involved nodes with fractions of 1.8 Gy, five days a week. A positional Megavoltage Computed Tomography was performed before each treatment session. All acute and late toxicities were graded according to Common Terminology Criteria for Adverse Events version 3.0. Survival analysis was performed using the Kaplan-Meier method. Results Median follow-up was 22.9 months. Fifty-four women and 10 men were treated (median age: 62 years). Nineteen patients (29.7 %) had T2, 16 patients (25.0 %) T3, and 27 patients (42.2 %) T4 tumours. Thirty-nine patients (60.9 %) had nodal involvement. Median tumour size was 45 mm (range, 10–110 mm). Seven patients had a colostomy before treatment initiation. Fifty-seven patients received concomitant chemotherapy (5-FU/cisplatin or 5-FU/mitomycin-based therapy). Forty-seven patients (73.4 %) experienced a complete response, 13 a partial response or local recurrence, and 11 had salvage surgery; among these, six became complete responders, three experienced metastatic failure, and two local failure. At least four patients experienced metastatic recurrence (concomitant to a local failure for one patient). The two-year overall survival was 85.6 % (95 %CI [71.1 %–93.0 %]), and the one-year disease-free survival, and colostomy-free survival were 68.7 % (95 %CI [54.4 %–79.4]), and 75.5 % (95 %CI [60.7 %–85.3 %]) respectively. Overall survival, disease-free survival and colostomy free-survival were significantly better for women than men (p = 0.002, p = 0.004, and p = 0.002 respectively). Acute grade ≥3 toxicity included dermatologic (46.9 % of patients), gastrointestinal (20.3 %), and hematologic (17.2 %) toxicity. Acute grade 4 hematologic toxicity occurred in one patient. No grade 5 event was observed. Conclusions TomoTherapy® for locally advanced anal cancer is feasible. In our three centres of expertise, this technique appeared to produce few acute gastrointestinal toxicities. However, high rates of dermatologic toxicity were observed. The therapeutic efficacy was within the range of expectations and similar to previous studies in accordance with the high rates of locally advanced tumours and nodal involvement.

The methodology and choice of criteria and indexes used for a common evaluation of helical tomotherapy by 3 French centres are described. After a selection of clinical indications and definition of the general purpose are successively described the criteria and index selected for: 1) description of volumes and adaptation for on board imaging; 2) dose prescription and constraints related to IMRT; 3) intercomparaison of volumes and doses and potential dosimetric gain with this new equipment.

e22501 Background: To evaluate efficacy and feasibility of radiotherapy (RT: high-level dose 54 Gy, with 30 fractions over / 6 weeks) followed by surgery, for retroperitoneal liposarcomas. Methods: Helical tomotherapy was used for pre-operative RT. Clinical Target Volume (CTV) and main organs at risk were systematically delineated with the surgeon. Surgery was planned 4 to 8 weeks after RT. Inclusion criteria were operable, biopsy-proven, retroperitoneal liposarcomas. Toxicity was graded according to CTCAE V3.0. Overall survival (OS) was estimated using Kaplan-Meier method. Due to competing risks, we estimated the cumulative incidence of loco-regional relapse; 95% confidence intervals are reported [95%CI]. Results: Patients:From 04/2009 to 09/2013, 48 patients were included. Mean age: 62 years (y) (36 to 82). All but 1 patient were OMS ≤ 2. Histological types were 20 well differentiated (WDLS) and 28 dedifferentiated liposarcomas. Mean CTV was 2954 cc. Treatment:1 patient did not have surgery. Dosimetric constraints were respected. Monobloc exerese was systematically achieved. Surgical margins were R0 (16; 34%), R1 (28; 60%), R2 (2; 4%) or missing (1; 2%). Oncological outcomes:Median follow-up was 4.7 y. Cumulative incidence of loco-regional relapse at 3 and 5 y was 17% [8%; 29%] and 31% [16%; 47%] respectively. Estimates were 5% and 35% for dedifferentiated liposarcoma and 26% and 26% for well differentiated liposarcoma. OS at 3 and 5 y was 81% [66%; 89%]) and 78% ([63%; 88%] respectively. Toxicity: 2 months after surgery, 10 grade 3 toxicities and 1 grade 4 toxicity were reported for 6 patients; 3 patients died within 6 months after surgery, 2 of which were related to treatment. After 1 y, no further severe toxicity was observed; 5 cases of second cancers were reported: 1 myeloid leukeamia, 2 pancreatic, 2 breast carcinomas. Conclusions: This trial highlights the feasibility of preoperative 54 Gy RT. Although efficacy data (local control and OS) are encouraging, high incidence rates of acute toxicities and second cancers should be considered. Preoperative RT for WDLS remains questionable. Results from ongoing EORTC phase III Strass trial may provide further level of evidence for this approach. Clinical trial information: NCT01841047.

The management of corticosteroids refractory chronic graft versus host disease (cGVHD) remains controversial. Retrospective analysis of patients treated at the Integrated Center of Oncology by total nodal irradiation (TNI) was performed to evaluate its therapy potency. TNI delivers a dose of 1 Gy in a single session. The delimitation of the fields is clinical (upper limit: external auditory meatus; lower limit: mid-femur). No pre-therapeutic dosimetry scanner was necessary. Evaluation of the efficacy was by clinical measures at 6 months after the treatment. Twelve patients were treated by TNI between January 2010 and December 2013. TNI was used in second-line treatment or beyond. The median time between allograft and TNI was 31.2 months, and the median time between the first manifestations of cGVHD and TNI was about 24.2 months. Of the 12 patients, nine had a clinical response at 6 months (75%), including five complete clinical responses (41.6%). Five patients could benefit from a reduction of corticosteroid doses. Three patients had hematologic toxicity. TNI could be considered as an option for the treatment of a cutaneous and/or soft tissues corticosteroids refractory cGVHD. However, prospective randomized and double-blind trials remain essential to answer the questions about TNI safety and effectiveness.

Objectifs La radiotherapie stereotaxique des metastases vertebrales permet de delivrer des doses elevees a la tumeur en epargnant la moelle epiniere. Les volumes cibles anatomocliniques sont definis sur l’IRM rachidienne selon le consensus international de radiochirurgie ( International Spine Radiosurgery Consortium [ISRC]). L’IRM est parfois prise a defaut et les images axiales reconstruites sont peu exploitables. Cette etude a evalue une nouvelle approche de delineation fondee sur l’imagerie phenotypique par immuno-TEP (peptide 68Ga-IMP-288 HSG precible par l’AcBs recombinant humanise trivalent anti-ACE x anti-HSG TF2) par rapport a l’IRM chez des patients atteints de metastases vertebrales d’un cancer du sein ou d’un cancer medullaire de la thyroide exprimant l’ACE. Materiel et methodes Les patients ont beneficie d’une immuno-TEP et d’une IRM. La segmentation des images d’immuno-TEP a ete realisee selon cinq modalites a partir du logiciel Dosisoft ® (SUV [ standard uptake value ] de 5, SUV de 2,5, seuil de 40 % de la SUVmax [SUV maximale], Adaptatif et Black) et determinait les segments vertebraux atteints par les metastases vertebrales. Les volumes cibles anatomocliniques d’apres l’immuno-TEP, etablis selon l’ISRC, ont ete compares a ceux d’apres l’IRM. Resultats Huit patients, atteints pour cinq de metastases de cancer du sein et trois de cancer medullaire de la thyroide, ont ete inclus. Cent trente-quatre metastases vertebrales ont ete evaluees : 46 eligibles a la radiotherapie stereotaxique en immuno-TEP, 30 en IRM. Onze metastases vertebrales etaient pathologiques en immuno-TEP sans lesion objectivee en IRM. Quatre-vingt-trois segments ont ete detectes a l’IRM et 72 en immuno-TEP. Deux seuillages etaient concordants avec la delineation des volumes en IRM : SUV de 2,5 et seuil de 40 % de la SUVmax. L’immuno-TEP detectait plus de lesions que l’IRM pour les corps vertebraux (44 contre 42), mais moins pour les pedicules (20 contre 33), lames et processus transverses (10 contre 16), et apophyses epineuses (0 contre 2). En comparant IRM et immuno-TEP, le volume cible anatomoclinique etait modifie dans 85 % des cas (39 sur 46). Parmi les 30 lesions eligibles a la radiotherapie stereotaxique en IRM, la delineation du volume cible anatomoclinique etait, en comparaison a l’immuno-TEP, identique pour 11 metastases vertebrales, majore pour 14 et diminue pour cinq. La determination des segments atteints etait plus facile en immuno-TEP en raison d’un plus fort contraste. Conclusion Du fait de son acquisition volumetrique et de sa fixation phenotypique l’immuno-TEP modifie le volume cible anatomoclinique des metastases vertebrales a traiter par irradiation stereotaxique dans 85 % des cas et detecte des lesions non visibles en IRM. En permettant une cartographie des segments atteints plus precise que l’IRM, l’immuno-TEP pourrait faciliter la determination du volume cible anatomoclinique de metastases vertebrales en radiotherapie stereotaxique.

Objectifs La radiotherapie en conditions stereotaxiques pulmonaire s’est imposee par ses bons resultats en termes de controle local et de tolerance comme nouveau standard therapeutique chez les patients atteints d’un carcinome bronchique non a petites cellules de stade 1 inoperables ou refusant la chirurgie. Notre etude avait pour objectif d’efficacite et la tolerance des 30 premiers traitements delivres dans le centre Rene-Gauducheau depuis 2011. Patients et methodes Trente patients ont ete traites en 3 ans et demi, tous atteints d’un cancer classe T1 ou T2N0M0, avec un accelerateur Novalis™, apres insertion d’un repere fiduciel et une scanographie dosimetrique (quadridimensionnelle en respiration libre ou en apnee expiratoire). Le protocole d’irradiation comprenait principalement quatre seances de 12 Gy prescrits sur l’isodose peripherique. Resultats L’âge moyen des patients etait de 71 ans, 23 cancers etaient de stade Ia (T1N0M0) et sept de stade Ib ou IIa (T2N0M0). La dose delivree a 50 % (D50) du volume tumoral macroscopique (GTV) etait en moyenne de 62,4 Gy. Le volume tumoral macroscopique moyen etait de 9 cm3, le volume cible previsionnel (PTV) de 33,9 cm3, avec des marges de 3 a 9 mm. Le suivi median etait de 15,2 mois. Trois patients ont ete atteints d’une pneumopathie radique aigue de grade 3 (10 %). La scanographie a montre a 3 mois 13 lesions stables, 15 en reponse partielle, deux en reponse complete et aucune en progression. Le taux de controle local etait de 100 % au cours du suivi. La probabilite de survie globale etait de 89,7 % apres un suivi median de 24mois. En revanche, trois patients ont ete atteints d’une evolution metastatique. Conclusion L’analyse des resultats obtenus dans notre etude confirme la faisabilite et l’interet d’une telle technique, transformant des indications palliatives en traitement curatif. Les etudes a venir diront si cette technique peut s’inscrire comme traitement de premiere intention chez tous les patients atteints d’un carcinome bronchique non a petites cellules de stade 1.

Les aberrations chromosomiques ont ete mesurees sur les lymphocytes de 30 patients (pts) irradies pour lymphome malin non-hodgkinien (LNH) selon 3 modalites : 20 Grays (Gy) sur l'abdomen (groupe 1 : 12 pts), irradiation corporelle totale 1,5 Gy (groupe II :12 pts), ou 15 Gy (groupe III : 6 pts). Une population non irradiee de 468 pts a servi de temoin. Dans le groupe irradie, 7 % des cellules presentaient des anomalies contre 0,4 % dans le groupe temoin (p < 10 -6 ). Les aberrations etaient statistiquement plus nombreuses dans le groupe I(12 % des cellules) que dans les groupes II (3,5 %) et III(2,5 %). Dans le groupe I, les anomalies etaient statistiquement plus frequentes chez les pts ayant eu une irradiation localisee extra-abdominale en complement de celle de l'abdomen ainsi que chez ceux en rechute de leur LNH et ceux recevant une chimiotherapie lors de l'etude cytogenetique.

To assess prospectively the prognostic value of FDG PET/CT during curative-intent radiotherapy (RT) with or without concomitant chemotherapy in patients with non-small-cell lung cancer (NSCLC).Patients with histological proof of invasive localized NSCLC and evaluable tumour, and who were candidates for curative-intent radiochemotherapy (RCT) or RT were preincluded after providing written informed consent. Definitive inclusion was conditional upon significant FDG uptake before RT (PET₁). All included patients had a FDG PET/CT scan during RT (PET₂, mean dose 43 Gy) and were evaluated by FDG PET/CT at 3 months and 1 year after RT. The main endpoint was death (from whatever cause) or tumour progression at 1 year.Of 77 patients preincluded, 52 were evaluable. Among the evaluable patients, 77% received RT with induction chemotherapy and 73% RT with concomitant chemotherapy. At 1 year, 40 patients (77 %) had died or had tumour progression. No statistically significant association was found between stage (IIIB vs. other), histology (squamous cell carcinoma vs. other), induction or concomitant chemotherapy, and death/tumour progression at 1 year. The SUVmax in the PET2 scan was the single variable predictive of death or tumour progression at 1 year (odds ratio 1.97, 95% CI 1.25 - 3.09, p = 0.003) in multivariate analysis. The area under the receiver operating characteristic curve was 0.85 (95% CI 0.73 - 0.94, p 10(-4)). A SUVmax value of 5.3 in the PET₂ scan yielded a sensitivity of 70% and a specificity of 92% for predicting tumour progression or death at 1 year.This prospective multicentre study demonstrated the prognostic value in terms of disease-free survival of SUVmax assessed during the 5th week of curative-intent RT or RCT in NSCLC patients (NCT01261598; RTEP2 study).