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Resume Objectif de l’etude Evaluer les indications actuelles et potentielles de la photobiomodulation (PBM) et leur niveau de preuve dans la prevention ou le traitement des effets secondaires lies a la radiotherapie. Materiels et methodes Les bases de donnees Embase, Medline/PubMed, Cochrane, EBSCO, Scopus, et LILACS ont systematiquement ete passees en revue afin d’inclure et d’analyser les publications d’etudes cliniques ayant evaluees la photobiomodulation dans la prevention ou la prise en charge des effets secondaires liees a la radiotherapie. Les mots-cles utilises etaient « photobiomodulation » ; « low level laser therapy » ; « acute oral mucositis » ; « acute dysphagia » ; « acute radiation dermatitis » ; « lymphedema » ; « xerostomia » ; « hyposalivation » ; « trismus » ; « bone necrosis » ; « osteoradionecrosis » ; « radiation induced fibrosis ». Les etudes prospectives ont ete incluses, alors que les cohortes retrospectives et les articles non originaux ont ete exclus de l’analyse. Resultats La photobiomodulation dans le spectre du rouge ou de l’infrarouge a demontre son efficacite dans des essais controles randomises dans la prevention et la prise en charge de certaines complications liees a la radiotherapie, en particulier de la mucite aigue, de l’epitheliite et du lymphœdeme du membre superieur. Le niveau de preuve associe a la photobiomodulation etait heterogene, mais restait globalement modere. Les principales limites etaient la diversite et la manque de precision des protocoles de traitement qui a pu compromettre l’efficience et la reproductibilite des resultats de la photobiomodulation. Conclusion Les donnees publiees suggerent que la photobiomodulation pourrait donc etre envisagee comme un soin de support a part entiere pour les patients traites par irradiation, au moins dans le cadre d’essai clinique therapeutique. Toutefois, tant que des donnees solides n’auront pas ete publiees sur son innocuite a long terme, l’utilisation de la photobiomodulation doit etre envisagee avec prudence, particulierement lorsqu’elle est pratiquee proche des zones avec des tumeurs connues ou possibles. Le patient doit etre informe des avantages et des risques theoriques de la photobiomodulation afin d’obtenir son consentement eclaire avant le traitement.

To evaluate the current and potential indications of photobiomodulation (PBM) and their level of evidence in the prevention or management of radiation therapy-related side effects.The Embase, Medline/PubMed, Cochrane, EBSCO, Scopus, and LILACS databases were systematically reviewed to include and analyze publications of clinical studies that have assessed PBM in the prevention or management of radiotherapy-related side effects. The keywords used were "photobiomodulation"; "low level laser therapy"; "acute oral mucositis"; "acute dysphagia"; "acute radiation dermatitis"; "lymphedema"; "xerostomia"; "hyposalivation"; "trismus"; "bone necrosis"; "osteoradionecrosis"; and "radiation induced fibrosis". Prospective studies were included, whereas retrospective cohorts and non-original articles were excluded from the analysis.PBM in the red or infrared spectrum has demonstrated efficacy in randomized controlled trials in the prevention and management of radiotherapy-related side effects, especially acute oral mucositis, acute radiation dermatitis, and upper extremity lymphedema. The level of evidence associated with PBM was heterogeneous, but overall was still moderate. The main shortcomings were the diversity and lack of detail in treatment protocols, which could have compromised efficiency and reproducibility of PBM results.The published data suggest that PBM may be considered as a full-fledged supportive care for patients treated with radiotherapy, or at least in the setting of a therapeutic clinical trial. However, until strong evidence has been published on its long-term safety, the use of PBM should be considered with caution, specifically when applied near areas with proven or potential tumors. The patient should be informed of the theoretical benefits and risks of PBM in order to obtain his informed consent before treatment.

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

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

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

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

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

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

Locally advanced oesophageal cancer treatment requires a multidisciplinary approach with the combination of chemotherapy and radiotherapy for preoperative and definitive strategy. Preoperative chemoradiation improves the locoregional control and overall survival after surgery for locally advanced oesophageal cancer. Definitive chemoradiation can also be proposed for non-resectable tumours or medically inoperable patients. Besides, definitive chemoradiation is considered as an alternative option to surgery for locally advanced squamous cell carcinomas. Chemotherapy regimen associated to radiotherapy consists of a combination of platinum derived drugs (cisplatinum or oxaliplatin) and 5-fluorouracil or a weekly scheme combination of carboplatin and paclitaxel according to CROSS protocol in a neoadjuvant strategy. Radiation doses vary from 41.4Gy to 45Gy for a preoperative strategy or 50 to 50.4Gy for a definitive treatment. The high risk of lymphatic spread due to anatomical features could justify the use of an elective nodal irradiation when the estimated risk of microscopic involvement is higher than 15% to 20%. An appropriate delineation of the gross tumour volume requires an exhaustive and up-to-date evaluation of the disease. Intensity-modulated radiation therapy represents a promising approach to spare organs-at-risk. This critical review of the literature underlines the roles of radiotherapy for locally advanced oesophageal cancers and describes doses, volumes of treatment, technical aspects and dose constraints to organs-at-risk.

Modern radiotherapy techniques (intensity-modulated radiotherapy, volumetric-modulated arctherapy, image-guided radiotherapy) or stereotactic radiotherapy are in expansion in most French cancer centres. The arrival of such techniques requires updates of existing equipment or implementation of new radiotherapy devices with adapted options. With the arrival of these new devices, there is a need to develop a quality and safety policy. This is necessary to ease the process from the setup to the first treated patient. The quality and safety policy is maintained to ensure the quality assurance of the radiotherapy equipment. We conducted a review of the literature on the quality and safety policy in the French legal framework that can be proposed when implementing a new radiotherapy device.

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

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

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

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

The treatment of rectal carcinoma is based on multidisciplinary strategy and multimodal approaches including gastrointestinal tract specialists, medical oncologists, radiation oncologists and surgery. The different objectives should be declined according to the characteristics of the tumours. The aim of the therapist would be to select the best strategy offering to the patient to be cured with as less as possible late adverse toxicity. The challenge of the treatment of small tumours is to maintain a functional anal sphincter while minimizing the risk of local recurrence. The standard treatment of locally advanced disease is aiming firstly to cure the patient and secondly to prevent late complications. Each of these clinical presentations of the disease has to be considered as a whole taking into account the new surgical techniques and a personalized approach adapted to the tumour. Nowadays they should be studied with dedicated clinical trials.

Objectif de l’etude Evaluer les pratiques professionnelles sur la prise en charge de la douleur sur le plateau technique de radiotherapie et caracteriser les douleurs ressenties par les patients durant le parcours de soins. Materiel et methode A partir d’un autoquestionnaire distribue en fin de radiotherapie aux patients ambulatoires, les caracteristiques (typologie, prevalence, prise en charge eventuellement recue) des douleurs ont ete relevees avant le traitement, lors des seances et durant les consultations en cours de traitement. Le nombre de sujets necessaires a ete estime a 139 a partir du pourcentage de patients douloureux observe dans les etudes, avec un intervalle de confiance a 95 %. Resultats Entre janvier et aout 2017, 130 questionnaires exploitables ont ete recueillis. La population etait a 54 % masculine avec un âge median de 60,5 ans. La moitie des patients avaient un traitement antalgique avant la prise en charge en radiotherapie, dont 35 % etaient incompletement soulages. La question de la douleur etait abordee dans plus de 75 % des cas lors des consultations medicales et a 21 % lors des seances. Le traitement antalgique preventif, s’il etait instaure (28 % des cas), faisait significativement baisser la prevalence (p = 0,0072) mais etait insuffisamment efficace (59 % avaient toujours mal). Par ailleurs, une douleur de fond avant la radiotherapie etait significativement associee a plus de douleurs lors des seances. Finalement, 82 % des patients declaraient etre satisfaits de leur prise en charge antalgique. Conclusion Il existe deux types de douleurs : la douleur provoquee par le cancer et la douleur induite par la radiotherapie, avec une forte prevalence, une intensite elevee et un important retentissement sur les activites de la vie quotidienne. Cette etude montre la necessite de rechercher, d’evaluer et d’anticiper la douleur des patients pris en charge en radiotherapie. La sensibilisation du personnel medical et paramedical est un vecteur d’amelioration du controle antalgique.

Objectif de l’etude La lymphopenie severe est une complication frequente de la chimioradiotherapie des cancers du pancreas. Des donnees recentes ont suggere un impact defavorable de la lymphopenie severe (inferieure ou egale a 0,5 × 109/L) sur la survie, avec une association directe entre la dose d’irradiation delivree a la rate et le risque de lymphopenie severe. Cependant, aucune contrainte dosimetrique dans la rate n’a ete validee pour la chimioradiotherapie des cancers du pancreas. L’objectif de cette etude etait de determiner les contraintes dosimetriques dans la rate susceptible de diminuer le risque de lymphopenie severe et d’ameliorer la probabilite de survie sans progression. Materiel et methode Une analyse retrospective des dossiers de 27 patients pris en charge par chimioradiotherapie a la Pitie-Salpetriere entre 2009 et 2017 pour un cancer du pancreas localement evolue a ete faite. La dose de prescription dans le volume cible previsionnel etait de 54 Gy en 30 fractions, en association a une chimiotherapie concomitante par capecitabine. La majorite des patients (63 %) a ete prise en charge par radiotherapie conformationnelle avec modulation d’intensite. Les contraintes dosimetriques analyses etaient la dose moyenne (DMrate), le V5 Gy, le V10 Gy et le V20 Gy (V × Gy : volume recevant × Gy). Les numerations-formules hebdomadaires ont ete recueillies pendant la chimioradiotherapie et jusqu’a 12 semaines apres. Le test t de Student a ete utilise pour l’analyse de la correlation entre les contraintes dosimetriques et la survenue d’une lymphopenie severe. L’analyse de la survie sans progression etait realisee avec le test du Log-rank et le modele de Cox. Resultats La survenue d’une lymphopenie severe etait frequente : 74 % (n = 20/27). La DMrate (p = 0,03), le V10 Gy = 0,002 et le V20 Gy (p = 0,02) etaient correlees avec un risque de lymphopenie severe, contrairement au V5 Gy (p = 0,09). En analyse unifactorielle, les parametres influencant la survie sans progression etaient la DMrate Conclusion La DMrate, le V10 Gy et le V20 Gy etaient correlees avec le risque de lymphopenie severe. Une meilleure probabilite de survie sans progression a ete observee avec une DMrate

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

Objectif de l’etude L’essai national randomise multicentrique Polca vise a determiner si le traitement des oligodendrogliomes anaplasiques nouvellement diagnostiques par six cycles de chimiotherapie associant la procarbazine, la carmustine et la vincristine (PCV) ameliore la probabilite de survie sans deterioration des fonctions cognitives (objectif primaire) comparativement au traitement standard (radiotherapie conformationnelle avec modulation d’intensite [RCMI] suivie de six cycles de PCV). Nous rapportons les resultats de la revue retrospective des dossiers techniques des patients randomises au 09/03/2018 afin d’evaluer le respect des recommandations du protocole. Materiel et methode Onze institutions ont adresse le dossier technique de radiotherapie de 40 patients. Les examens d’imagerie et les dossiers techniques de radiotherapie ont ete revus par au moins trois experts independants, membres du Granocef. L’evaluation des contours et de la dosimetrie a ete realisee a l’aide du logiciel Artiview® (Aquilab SAS, France). Resultats Trente-quatre des 40 dossiers (72,3 %) etaient evaluables. Dix-huit dossiers techniques etaient conformes aux exigences du protocole (53 %), trois ont ete consideres comme acceptables (9 %), et 13 dossiers (38 %) presentaient des deviations majeures. Ces deviations majeures etaient liees a la definition des volumes cibles (dix cas), a la delineation des organes a risque (sept cas), a l’etude dosimetrique (deux cas), aux sequences d’IRM utilisees (deux cas) et au non emploi de la RCMI (un cas). Conclusion Cette analyse montre un nombre significatif (38 %) de deviations majeures au protocole de radiotherapie dans l’essai Polca. Ces deviations ont un potentiel impact sur le controle tumoral mais aussi sur la survenue d’effets secondaires. Il est donc propose par souci d’amelioration un dummy-run de delineation, la redaction d’un document listant les principales deviations, une participation plus large des oncologues radiotherapeutes aux reunions du Granocef. Pour les futures etudes, une evaluation prospective individuelle devrait etre realisee avant l’irradiation.

Objectif de l’etude Le traitement de reference des glioblastomes comporte apres la chirurgie une radiotherapie associee a du temozolomide en concomitance suivie par du temozolomide adjuvant. Les patients atteints de glioblastome multifocal sont souvent traites par du temozolomide seul sans irradiation cerebrale. A notre connaissance, aucune etude n’a evalue le role de l’irradiation encephalique in toto associee au temozolomide concomitant et adjuvant chez des patients atteints d’un glioblastome multifocal. Nous rapportons retrospectivement les resultats de l’irradiation encephalique in toto associee au temozolomide concomitant et adjuvant. Materiel et methode Entre avril 2009 et septembre 2017, 11 patients atteint d’un glioblastome multifocal (plus de trois lobes) ont ete pris en charge par chimioradiotherapie premiere. L’âge median etait de 50 ans [34–74]. La dose mediane de radiotherapie etait de 45 Gy en 25 fractions de 1,8 Gy avec un etalement de 37 jours [29–41]. Le temozolomide etait administre concomitamment a la radiotherapie a une dose de 75 mg/m2/j, puis en situation adjuvante a la dose de 150–200 mg/m2 (j1–j5) tous les mois. L’evaluation de l’etat general au moyen de l’indice de Karnofsky etait au moment du diagnostic de 80 % [30–90]. Resultats Les durees medianes de survie globale et la survie sans progression etaient respectivement de 10 mois [4–25] et 5 mois [3–21]. L’indice de Karnofsky etait stable un mois apres la fin de la radiotherapie. Pendant la chimioradiotherapie, la dose de corticotherapie etait stable ou en diminution chez cinq patients. En dehors de l’alopecie, aucune toxicite de grade 3–4 liee a la radiotherapie n’a ete notifiee. Le temozolomide a ete arrete chez un patient durant la chimioradiotherapie pour une thrombopenie de grade 4. Pour les autres cas de toxicite de grade 3–4 liee au temozolomide, deux lymphopenies de grade 3 ont ete rapportees. Le temozolomide adjuvant a ete administre chez neuf patients avec un nombre median de cycles de cinq [2–12]. Conclusion Notre etude est en faveur de l’efficacite et de la bonne tolerance immediate de l’irradiation encephalique in toto avec du temozolomide concomitant et adjuvant pour les patients atteints d’un glioblastome multifocal nouvellement diagnostique.

Objectif de l’etude L’objectif de cette etude retrospective monocentrique etait d’evaluer les differentes modalites de radiotherapie en conditions stereotaxiques des metastases cerebrales de cancer du rein. Materiel et methode Cent vingt patients atteints d’un cancer du rein ont ete pris en charge pour une irradiation cerebrale en conditions stereotaxiques a la Pitie-Salpetriere de 2005 a 2015, soit 398 metastases traitees. L’âge median etait de 58 ans (extremes : 31–82 ans). La duree mediane entre le diagnostic de cancer du rein et l’apparition de la premiere metastase cerebrale etait de 24 mois (extremes : 0–252 mois). Resultats Le nombre median de metastases cerebrales par patient etait de deux (extremes : 1–46). Le diametre median des metastases etait de 13 mm (extremes : 1–60 mm). Cent quatre-vingt-sept radiotherapies en conditions stereotaxiques ont ete analysees pour les 120 patients. Soixante et un patients (226 metastases) pris en charge par GammaKnife® ont recu une dose mediane sur l’isodose 50 % de prescription de 18 Gy (extremes : 14–22 Gy). Les medianes des doses minimale et maximale etaient de 18,4 Gy (extremes : 12,5–40,1 Gy) et 36 Gy (extremes : 23,3–51,2 Gy). Cent trente-six metastases chez 63 patients ont ete traitees par un accelerateur lineaire (photons de 10 MV). Les medianes des doses minimale (isodose 70 %) et maximale (isocentre) etaient de 16 Gy (extremes : 9,8–25,8 Gy) et 20,3 Gy (extremes : 15,3–33,74 Gy). La duree mediane de survie globale etait de 14 mois (extremes : 0,5–147 mois). Les taux de controle tumoral a 3, 6, 12 mois etaient respectivement de 86 %, 62 %, 36 %. Sur les 187 irradiations, 95 (51 %) ont ete suivies d’une progression cerebrale, dans un delai median de 5 mois (1–81), 81 progressions (85 %) sont survenues sous forme de nouvelle(s) lesion(s) et 25 (26 %) d’une recidive locale. Les analyses des facteurs pronostiques associes a la survie sont en cours. Conclusion L’irradiation en conditions stereotaxiques permet un taux de controle eleve des metastases cerebrales de cancer du rein sans recours a l’irradiation de l’encephale en totalite. Les deux modalites presentent des caracteristiques differentes dont les avantages seront analyses avec l’etude des facteurs pronostiques et predictifs de controle local.

Natural killer (NK)/T-cell lymphoma are part of lymphoproliferative diseases, they are rare in Europe and the United States but relatively common in Asia and South America. Natural killer (NK)/T-cell lymphoma present clinically as destructive lesions of the upper aerodigestive tract with perforation of deep structures of the face, destruction of the palate or an invasion of orbits. Treatment modalities of these lymphomas are still discussed because of the lack of available studies and the rarity of this disease. Radiotherapy provides a rapid control of the disease and is positioned as a major treatment of localized stages of NK/T-cell lymphoma of the nasal cavity. We therefore studied the different forms of radiation therapy in the early stages of nasal NK/T-cell lymphoma.

To review in the literature, all the epidemiological, clinical, radiological, histological and therapeutic data regarding chordomas as well as various notochordal entities: ecchordosis physaliphora, intradural and intraparenchymatous chordomas, benign notochordal cell tumors, parachordomas and extra-axial chordomas. To identify different types of chordomas, including familial forms, associations with tuberous sclerosis, Ollier's disease and Maffucci's syndrome, forms with metastasis and seeding. To assess the recent data regarding molecular biology and progress in targeted therapy. To compare the different types of radiotherapy, especially protontherapy and their therapeutic effects. To review the largest series of chordomas in their different localizations (skull base, sacrum and mobile spine) from the literature.The series of 136 chordomas treated and followed up over 20 years (1972-2012) in the department of neurosurgery at Lariboisière hospital is reviewed. It includes: 58 chordomas of the skull base, 47 of the craniocervical junction, 23 of the cervical spine and 8 from the lombosacral region. Similarly, 31 chordomas in children (less than 18 years of age), observed in the departments of neurosurgery of les Enfants-Malades and Lariboisière hospitals, are presented. They were observed between 1976 and 2010 and were located intracranially (n=22 including 13 with cervical extension), 4 at the craniocervical junction level and 5 in the cervical spine.In the entire Lariboisière series and in the different groups of localization, different parameters were analyzed: the delay of diagnosis, of follow-up, of occurrence of metastasis, recurrence and death, the number of primary patients and patients referred to us after progression or recurrence and the number of deaths, recurrences and metastases. The influence of the quality of resection (total, subtotal and partial) on the prognosis is also presented. Kaplan-Meier actuarial curves of overall survival and disease free survival were performed in the entire series, including the different groups of localization based on the following 4 parameters: age, primary and secondary patients, quality of resection and protontherapy. In the pediatric series, a similar analysis was carried-out but was limited by the small number of patients in the subgroups.In the Lariboisière series, the mean delay of diagnosis is 10 months and the mean follow-up is 80 months in each group. The delay before recurrence, metastasis and death is always better for the skull base chordomas and worse for those of the craniocervical junction, which have similar results to those of the cervical spine. Similar figures were observed as regards the number of deaths, metastases and recurrences. Quality of resection is the major factor of prognosis with 20.5 % of deaths and 28 % of recurrences after total resection as compared to 52.5 % and 47.5 % after subtotal resection. This is still more obvious in the group of skull base chordomas. Adding protontherapy to a total resection can still improve the results but there is no change after subtotal resection. The actuarial curve of overall survival shows a clear cut in the slope with some chordomas having a fast evolution towards recurrence and death in less than 4 years and others having a long survival of sometimes more than 20 years. Also, age has no influence on the prognosis. In primary patients, disease free survival is better than in secondary patients but not in overall survival. Protontherapy only improves the overall survival in the entire series and in the skull base group. Total resection improves both the overall and disease free survival in each group. Finally, the adjunct of protontherapy after total resection is clearly demonstrated. In the pediatric series, the median follow-up is 5.7 years. Overall survival and disease free survival are respectively 63 % and 54.3 %. Factors of prognosis are the histological type (atypical forms), localization (worse for the cervical spine and better for the clivus) and again it will depend on the quality of resection.Many different pathologies derived from the notochord can be observed: some are remnants, some may be precursors of chordomas and some have similar features but are probably not genuine chordomas. To-day, immuno-histological studies should permit to differentiate them from real chordomas. Improving knowledge of molecular biology raises hopes for complementary treatments but to date the quality of surgical resection is still the main factor of prognosis. Complementary protontherapy seems useful, especially in skull base chordomas, which have better overall results than those of the craniocervical junction and of the cervical spine. However, we are still lacking an intrinsic marker of evolution to differentiate the slow growing chordomas with an indolent evolution from aggressive types leading rapidly to recurrence and death on which more aggressive treatments should be applied.

Central neurocytoma is a rare primary central nervous system tumour of young adults with good prognosis. Typical and atypical forms are described according to various histologic and histopathologic parameters. Central neurocytoma develops in the periventricular areas and is revealed by increased intracranial pressure. The tumour exhibits typical characteristics on CT scan and MRI and a characteristic peak of glycine on spectroscopy-MRI. The main treatment is total resection, which is achievable only in half of the cases. External beam therapy improves local control of partially resected and/or atypical central neurocytoma. Many studies show that stereotactic radiotherapy can be used in the therapeutic management as exclusive treatment, in postoperatives residues and in case of distant recurrence. Chemotherapy is the last line of treatment in refractory forms, especially in the forms with extracranial and/or neuromeningeal spread and in recurrent forms after treatment with surgery and/or radiotherapy.

Natural killer (NK)/T-cell lymphoma are part of lymphoproliferative diseases, they are rare in Europe and the United States but relatively common in Asia and South America. Natural killer (NK)/T-cell lymphoma present clinically as destructive lesions of the upper aerodigestive tract with perforation of deep structures of the face, destruction of the palate or an invasion of orbits. Treatment modalities of these lymphomas are still discussed because of the lack of available studies and the rarity of this disease. Radiotherapy provides a rapid control of the disease and is positioned as a major treatment of localized stages of NK/T-cell lymphoma of the nasal cavity. We therefore studied the different forms of radiation therapy in the early stages of nasal NK/T-cell lymphoma.