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Stereotactic radiosurgery (SRS) is a non-invasive technique that enables to create brain focal lesions with a high precision and localization. Thus, functional brain disorders can be treated by SRS in case of pharmacoresistance or inoperability. To date, treatment of trigeminal neuralgia is the most described and known indication. Other indications will be developed in the future like movement disorders, refractory epilepsy, obsessive compulsive disorder and severe depression. We present here a review of actual and future indications of functional brain SRS with their level of evidence. All these SRS treatments have to be strictly conducted by trained teams with an excellent collaboration between radiation physicists, medical physicists, neurosurgeons, neurologists, psychiatrists and probably neuroradiologists.

Highlights • No correlation between radiotherapy and the development of MS is to date described. • Demyelination can occur after radiotherapy in tissue adjacent to irradiated tumours. • MS lesions seem to occur in regions irradiated with a mean BED2 of 34 Gy. • Caution is needed among 35 - 45-year-old patients or with demyelinating illnesses. • MS should be kept in mind as differential diagnosis of metastases or radionecrosis., Introduction Demyelination can occur after brain radiotherapy in tissue adjacent to irradiated tumours. To date, no correlation has been found between conventional-dose radiotherapy and the development of multiple sclerosis, but radiotherapy could be a triggering factor among women with known multiple sclerosis. To the best of our knowledge, this is the first well-documented case of this association with a dosimetric analysis. Case presentation The case we report here describes the development of multiple sclerosis in a 36-year-old woman without significant past medical history 3 months after the last session of fractionated stereotactic radiotherapy for a pituitary macroadenoma. Our dosimetric analysis suggests that all the multiple sclerosis lesions occurred in the brain regions irradiated with a mean biologically effective dose (BED2) of 33.9 Gy (27.3–49.6 Gy). Conclusion Consequently special caution towards radiotherapy is required among patients with demyelinating illnesses or for 35–45-year-old women who are at risk. In addition, multiple sclerosis lesions can look like metastases. We should therefore keep differential diagnoses in mind in order not to make mistakes that would delay treatment.

Hypofractionated stereotactic radiotherapy and stereotactic radiosurgery are major therapeutic weapons in the brain, whether for tumor, vascular or functional treatments. They tend increasingly to democratize and to become standard treatments. However, human brain anatomy is very complex and not limited to the currently described organs at risk. Diffusion tensor imaging (DTI) tractography is a simple tool that enables to identify reproducibly big white matter fiber tracts. Not only does tractography allow a redefinition of organs at risk in the brain, but it would also allow the identification of new targets, such as the ventral intermediate nucleus (Vim) within the thalamus for treatment of movement disorders. We present here a review of the role of tractography and the anatomy, function and currently described dose-effect relationships of white matter fiber tracts with a major functional impact: the pyramidal tract for motor ability, the optic radiation for vision and the arcuate fasciculus for language.

Stereotactic radiotherapy (SRT) is the standard treatment for brain metastases of non-small-cell lung cancer (NSCLC) and melanoma, mostly in combination with immunotherapy. The objective was to retrospectively evaluate the influence of the time-lapse between immunotherapy and stereotactic radiotherapy on toxicity.From 2016 to 2019, 59 patients treated with SRT for 103 brain metastases of NSCLC (60%) and melanoma (40%) in combination with concomitant immunotherapy (≤30 days) were included. The prescribed dose was 20Gy/1f or 33Gy/3f at the isocentre and 14Gy or 23.1Gy (70%) respectively at the PTV envelope (PTV=GTV+2mm). The mean tumour diameter was 14mm (4-52mm). The immunotherapies used were anti-PD1 and anti-PDL1. The 103 metastases were classified into 3 groups according to the time-lapse between instatement of immunotherapy and instatement of SRT for the patient concerned: 7 (7%) in group A (≤7 days), 38 (37%) in group B (7 to 14 days) and 58 (56%) in group C (14 to 30 days).The mean follow-up was 10.1 months. The median overall survival was 11.5 months for NSCLC and 12.5 months for melanoma. The percentage of local control (LC) at one year was 65.1% (93.6% for NSCLC and 26.5% for melanoma). The time-lapse between immunotherapy and SRT was not a significant predictor of LC (P=0.86), while the histology was (P0.001). The proportion of grade≥3 toxicities was 5.1%, and that of radionecrosis was 9.7% (among these patients, 80% were non-symptomatic): 0%, 13.1% and 8.6% for groups A, B and C respectively. The time-lapse between immunotherapy and SRT was not a significant predictor of toxicity. Only tumour volume was a significant predictive factor (P=0.03).The time lapse between immunotherapy and SRT does not influence brain toxicity. The tumour volume remains the main factor.

International audience; Background: Stereotactic radiotherapy (SRT) should be applied with a biologically effective dose with an α/β of 12 (BED12) ≥ 40 Gy to reach a 1-year local control (LC) ≥ 70%. The aims of this retrospective study were to report a series of 81 unresected large brain metastases treated with Linac-based multifraction SRT according to the ICRU 91 and to identify predictive factors associated with LC.Methods: Included in this study were the first 81 brain metastases (BM) consecutively treated with Linac-based volumetric modulated arc therapy (VMAT) multifraction SRT from 2017 to 2019. The prescribed dose was 33 Gy for the GTV and 23.1 Gy (70% isodose line) for the PTV in 3 fractions (3f). Mean BM largest diameter and GTV were 25.1 mm and 7.2 cc respectively. Mean follow-up was 10.2 months.Results: LC was 79.7% and 69.7% at 1 and 2 years respectively. Significant predictive factors of LC were GTV D98% (HR = 0.84, CI 95% = 0.75-0.95, p = 0.004) and adenocarcinoma as the histological type (HR = 0.29, CI 95% = 0.09-0.96, p = 0.042) in univariate and multivariate analysis. A threshold of 29 Gy for GTV D98% was significantly correlated to LC (1-year LC = 91.9% for GTV D98% ≥ 29 Gy vs 69.6% for GTV D98% < 29 Gy (p = 0.030)), corresponding to a BED12 = 52.4 Gy. No tumor progression was observed for a BED12 ≥ 53.4 Gy, corresponding to a GTV D98% ≥ 20 Gy /1f and GTV D98% ≥ 29.4 Gy 3f. Median OS was 15 months. Symptomatic radionecrosis occurred in 4.9% of cases.Conclusion: The GTV D98% is a strong reproducible significant predictive factor of LC for brain SRT. Dose prescription should lead to a GTV BED12 98% ≥ 52.4-53.4 Gy to significantly improve LC, corresponding to respectively a GTV D98% ≥ 19.7-20 Gy/1f and 29-29.4 Gy/3f.

Background Numerous studies have assessed the predictive factors for the arteriovenous malformation (AVM) response to stereotactic radiosurgery (SRS). However, only a few have discussed the causes of failure. The aim of the present study was to evaluate the patterns of failure in patients with AVM who had undergone linear accelerator SRS. Methods We performed a retrospective analysis of 288 patients who had undergone linear accelerator SRS in our institution from 1995 to 2011. Failure was defined from the findings of the follow-up angiogram at 5 years, with failure identified in 44 patients. The distribution of causes was estimated using a descriptive analysis of literature-based causes, including a minimal margin dose of Results Incomplete nidus identification (41%) and previous embolization (77%) were the most frequently observed conditions in patients with failure. Patients who had undergone previous embolization, for whom the cause of failure had always been identified (P = 0.001), were younger (P = 0.004) and had had a larger nidus volume (P = 0.025). Recanalization was rare (5 of 34 patients) and had occurred exclusively in women (P = 0.048). Larger nidus volumes were less frequent (mean, 2.18 ± 2.2 cm3; range, 0.13–10.8 cm3) and had been observed mainly in women when >2 cm3 (P = 0.012). An insufficient dose was observed in 9 patients and had occurred in the case of a larger volume (P = 0.031), which had resulted in dosimetry constraints in 3 patients and treatment in the vicinity of eloquent zones in 6 patients. No known cause was found in 5 patients, 4 of whom had had a low Spetzler-Martin grade (I and II; P = 0.003), suggestive of radioresistance. Conclusion The results of our detailed analysis have highlighted the distribution of the causes of failure and the potential role of radioresistance in treatment failure.

Stereotactic radiotherapy is a major issue in the management of brain metastases. Radionecrosis is a major concern, especially for large lesions. Optimizing dosimetric parameters is essential to allow optimal local control rate while minimizing potential toxicity. We report the case of a 30-mm brain metastases treated with stereotactic radiotherapy after initial whole brain radiotherapy, complicated with symptomatic radionecrosis. A dose of 24Gy in three fractions on the 80% isodose were delivered using a dynamic conformal arc technique (Novalis TX®). We realized a dosimetric comparison with: (i) optimization of initial conformal arc plan, (ii) volumetric modulated arctherapy with coplanar arcs and (iii) volumetric modulated arctherapy with coplanar and non-coplanar arcs. The optimal dose planning in terms of planning target volume coverage (99.2%) and normal brain sparing (V24Gy=0.4cm3, V18Gy=6.5cm3, V10Gy=25.4cm3, V5=83.9cm3) was obtained with volumetric modulated arctherapy with coplanar and non-coplanar arcs. Volumetric modulated arctherapy-based stereotactic irradiation with coplanar and non-coplonar arcs seems an interesting option for the treatment of large brain metastases to optimize dosimetric parameters.

Resume Objectif de l’etude Description de l’implantation de la radiotherapie en conditions stereotaxiques pulmonaire sur accelerateur lineaire d’electrons Novalis Tx ® et analyse prospective des 100 premiers nodules pulmonaires traites au centre Jean-Perrin. Materiels et methodes D’octobre 2012 a decembre 2015, 100 nodules inoperables (62 carcinomes bronchiques non a petites cellules de stade I et 38 metastases) de 90 patients d’âge moyen de 68,2 ans (extremes : 46–89 ans) ont ete pris en charge prospectivement par arctherapie dynamique sur Novalis Tx ® , 87 % des nodules etaient peripheriques. Les volumes tumoraux macroscopiques et cibles previsionnels moyens etaient respectivement de 6,9 cm 3 (extremes : 0,2–31,4 cm 3 ) et 38,7 cm 3 (extremes : 1,7–131 cm 3 ), soit des diametres moyens respectifs d’environ 2,3 cm et 4,2 cm. Les doses prescrites sur l’isodose 80 % etaient 54 Gy en trois fractions pour les carcinomes bronchiques non a petites cellules peripheriques, 50 Gy en cinq fractions pour les carcinomes bronchiques non a petites cellules centraux et 45 Gy en trois fractions pour les nodules metastatiques. Les patients ont ete suivis tous les trois mois pour evaluer l’efficacite selon les criteres Response Evaluation Criteria In Solid Tumors (RECIST) et la toxicite selon la Common Terminology Criteria for Adverse Events (CTCAE v4). Le suivi moyen etait 12,5 mois. Resultats Le taux de reponse complete etait de 23,8 %. Les taux de controle local etaient de 100 % et 90,7 % respectivement a 12 et 24 mois, dont 96 % a 24 mois pour les nodules primitifs. Les taux de survie globale des patients atteints de carcinome bronchique non a petites cellules de stade I etaient respectivement de 77,4 % et 73,5 % a 12 et 24 mois (mediane de survie globale de 32 mois). En analyse unifactorielle, un coefficient de diffusion du CO corrige selon le volume alveolaire de moins de 40 % etait un facteur pronostique statistiquement significatif ( p = 0,00013). Au moins trois deces etaient en rapport avec une insuffisance respiratoire aigue, soit environ 4,8 % de pneumopathies radiques de grade 5. Pour les patients atteints de metastases, les taux de survie globale etaient de 95,2 % et 59,5 % respectivement a 12 et 24 mois (mediane de survie globale de 25 mois) ; 23,3 % de pneumopathies radiques de grade 2 ou moins, 7,8 % d’epitheliites de grade 2 ou moins, 2,2 % de fractures costales et 3,3 % de douleurs costales de grade 2 ou moins ont ete observes. Conclusion La radiotherapie en conditions stereotaxiques pulmonaire est un traitement efficace selon notre experience chez des patients rigoureusement selectionnes et informes. L’etat respiratoire initial de ces patients, et principalement le coefficient de diffusion du CO corrigee pour le volume alveolaire, semble determinant pour la tolerance a l’irradiation.

International audience; Purpose: Stereotactic radiotherapy plays a major role in the treatment of brain metastases (BM). We aimed to compare the dosimetric results of four plans for hypofractionated stereotactic radiotherapy (HFSRT) for large brain metastases.Material and methods: Ten patients treated with upfront NovalisTx® non-coplanar multiple dynamic conformal arcs (DCA) HFSRT for≥25mm diameter single BM were included. Three other volumetric modulated arc therapy (VMAT) treatment plans were evaluated: with coplanar arcs (Eclipse®, Varian, VMATcEclipse®), with coplanar and non-coplanar arcs (VMATncEclipse®), and with non-coplanar arcs (Elements Cranial SRS®, Brainlab, VMATncElements®). The marginal dose prescribed for the PTV was 23.1Gy (isodose 70%) in three fractions. The mean GTV was 27mm3.Results: Better conformity indices were found with all VMAT techniques compared to DCA (1.05 vs 1.28, P

Aims Although several studies on outcomes following stereotactic radiosurgery (SRS) for benign meningiomas have been reported, Linac-based SRS outcomes have not been as widely evaluated. The aim of this retrospective institutional single-centre study was to determine long-term outcomes of Linac-based SRS for benign intracranial meningiomas. Materials and methods From July 1996 to May 2011, 60 patients with 69 benign meningiomas were included. All patients were treated with single-fraction Linac-based SRS with four to five non-coplanar arcs, dynamic or not. The marginal dose prescribed for the periphery was 16 Gy. Prognostic factors associated with local control, progression-free survival (PFS) and overall survival were tested. Results The median follow-up was 128 months. No patient was lost to follow-up. The values observed at 1, 5 and 10 years were, respectively, 100%, 98.4% and 92.6% for local control, 94.9%, 93.2% and 78% for PFS and 100%, 94.7% and 92.7% for overall survival. In univariate analysis, local control after SRS was significantly higher for skull base and parasagittal meningiomas compared with convexity meningiomas (P = 0.031). Multivariate analyses showed significantly longer PFS when the minimum dose delivered to the tumour was greater than 10 Gy (P = 0.0082). No grade 5 toxicity was reported. Conclusion Our long-term results from a large sample size of benign meningiomas treated with Linac-based SRS confirmed excellent local control (>90%) and good safety, which is in line with published studies on Gamma Knife surgery. Above all, we showed significantly poorer PFS if the minimum dose to the tumour was under 10 Gy.

The rate of local failure of stage IIIA-N2 non-small cell lung cancer is 20 to 40%, even if they are managed with surgery and adjuvant chemotherapy. Postoperative radiotherapy improves local control, but its benefit on global survival remains to be demonstrated. Considered for many years as an adjuvant treatment option for pN2 cancers, it continues nevertheless to be deemed too toxic. What is the current status of postoperative radiotherapy? The Lung Adjuvant Radiotherapy Trial (Lung ART) phase III trial should give us a definitive, objective response on global survival, but inclusion of patients is difficult. The results are consequently delayed. The aim of this review is to show all the results about efficacy and tolerance of postoperative radiotherapy and to define the target volume and dose to prescribe.

In the present study, we have evaluated the efficacy and toxicity of repeated brain metastases (BM) stereotactic radiosurgery (SRS2) following local failure of a prior radiosurgical procedure (SRS1). Between December 1996 and August 2015, 30 patients with 36 BM underwent SRS2 with a median dose of 18Gy. All BM were located outside critical structures. Following SRS2, local control at 6 months and one year were respectively 82.9% (IC 95%: 67.6-91.9) and 67.8% (IC 95%: 51-81). On multivariate analysis, planning target volume (PTV) < 3cc (HR: 0.19 (0.1-0.52)) and whole brain radiotherapy (WBRT) prior to SRS2 (HR: 0.25 (0.1-0.64)) were significantly associated with a better local control. One- and two-year overall survival rates after SRS2 were respectively 65.5% (IC 95%: 47.3-80%) and 27.6% (IC 95%: 14.7-45.7). Median overall survival following SRS2 was 14.2 months (range 1-106). Nineteen (63%) patients died from progressive systemic disease. Three (10%) patients died from out-field progressive brain disease and 8 (27%) in-field. Concerning toxicities, edema, radionecrosis, and hemorrhages were identified in 5 (12.8%), 4 (10.2%), and 5 (12.8%) patients respectively. No toxicity resulted in a neurological deficit. On univariate analysis, toxicities were significantly associated with PTV > 7cc (p = 0.02) and all patients had a WBRT before SRS2. A second course of SRS for locally recurrent brain metastases showed encouraging rates of local control. This treatment led to acceptable toxicities, especially for brain metastases smaller than 7cc, in our selected cohort of patients with BM located outside critical structures. Further studies are needed.

Prostate cancer is the most frequent cancer among European males with a high survival rate. The economic impact of treatments and follow-up are significant. The objectives of the follow-up after prostate radiotherapy is multiple: diagnosis and treatment of side-effects, early detection of biochemical recurrence, with the aim of proposing a second local treatment to improve quality of life or overall survival and feedback of the treatment results to better inform patients at the beginning of the disease. This article reports incidence of main side-effects (digestive, urinary and sexual) with their treatments and guidelines for clinical and biological follow-up with strategies of imaging studies and salvage treatments.

Background The optimization of the management for elderly glioblastoma patients is crucial given the demographics of aging in many countries. We report the outcomes for a “real-life” patient cohort (i.e. unselected) comprising consecutive glioblastoma patients aged 70 years or more, treated with different radiotherapy +/− temozolomide regimens. Methods From 2003 to 2016, 104 patients ≥ 70 years of age, consecutively treated by radiotherapy for glioblastoma, were included in this study. All patients were diagnosed with IDH-wild type glioblastoma according to pathological criteria. Results Our patient cohort comprised 51 female patients (49%) and 53 male. The median cohort age was 75 years (70–88), and the median Karnofsky performance status (KPS) was 70 (30–100). Five (5%) patients underwent macroscopic complete resection, 9 (9%) had partial resection, and 90 (86%), a stereotactic biopsy. The MGMT promoter was methylated in 33/73 cases (45%). Fifty-two (50%), 38 (36%), and 14 (14%) patients were categorized with RPA scores of III, IV, and I-II. Thirty-three (32%) patients received normofractionated radiotherapy (60 Gy, 30 sessions) with temozolomide (Stupp), 37 (35%) received hypofractionated radiotherapy (median dose 40 Gy, 15 sessions) with temozolomide (HFRT + TMZ), and 34 (33%) HFRT alone. Patients receiving only HFRT were significantly older, with lower KPSs. The median overall survival (OS; all patients) was 5.2 months. OS rates at 12, 18, and 24 months, were 19%, 12%, and 5%, respectively, with no statistical differences between patients receiving Stupp or HFRT + TMZ (P = 0.22). In contrast, patients receiving HFRT alone manifested a significantly shorter survival time (3.9 months vs. 5.9 months, P = 0.018). In multivariate analyses, the prognostic factors for OS were: i) the type of surgery (HR: 0.47 [0.26–0.86], P = 0.014), ii) RPA class (HR: 2.15 [1.17–3.95], P = 0.014), and iii) temozolomide use irrespective of radiotherapy schedule (HR: 0.54 [0.33–0.88], P

Stereotactic radiotherapy is a major issue in the management of brain metastases. Radionecrosis is a major concern, especially for large lesions. Optimizing dosimetric parameters is essential to allow optimal local control rate while minimizing potential toxicity. We report the case of a 30-mm brain metastases treated with stereotactic radiotherapy after initial whole brain radiotherapy, complicated with symptomatic radionecrosis. A dose of 24Gy in three fractions on the 80% isodose were delivered using a dynamic conformal arc technique (Novalis TX

Adrenal glands are a common site for metastatic spread since they represent the fourth metastatic site of solid tumors. Interest in local ablative treatments of oligometastases is growing since literature suggests better progression-free survival, quality of life and potentially overall survival in selected patients. Surgery remains the first treatment of adrenal oligometastases because results are good, with a long enough follow-up. However, stereotactic radiotherapy appears to be comparable to surgery and could be proposed to elderly, unfit, inoperable patients, or even to patients whose systemic treatment should not be suspended for too long. This article aims to present a review of published studies to date on stereotactic radiotherapy of adrenal metastases and to propose a treatment protocol.

Introduction et but de l’etude L’evolution metastatique surrenalienne isolee d’un cancer necessite un changement de traitement systemique ou une radiotherapie stereotaxique hypofractionnee. L’objectif de cette etude prospective monocentrique etait d’etudier l’efficacite et la tolerance de la radiotherapie stereotaxique hypofractionnee des oligometastases surrenaliennes. Materiel et methodes De decembre 2016 a mars 2019 neuf patients avec 11 oligometastases surrenaliennes ont ete pris en charge. Les cancers primitifs etaient des melanomes (45,5 %), des cancers pulmonaires (36,4 %) et renaux (18,2 %). Sept patients etaient sous immunotherapie au moment de la radiotherapie stereotaxique hypofractionnee et deux sans traitement systemique. Tous etaient atteints d’une progression unique sur leur cible surrenalienne necessitant theoriquement, en l’absence de radiotherapie stereotaxique hypofractionnee, un changement de traitement systemique. Une marge de 3 mm etait ajoutee aux volumes tumoraux macroscopiques quadridimensionnels pour obtenir les volumes cibles previsionnels. Les volumes tumoraux macroscopiques et cible previsionnels medians etaient respectivement 19,1 cm3 (extremes : 2–127 cm3) et 46 cm3 (extremes : 13–171 cm3), avec un grand diametre median de volume tumoral macroscopique de 3,7 cm (extremes : 2–7,4 cm). La dose prescrite mediane etait 35 Gy en cinq fractions (dose biologique effective avec un rapport α/β de 10 Gy [BED10] = 59,5 Gy) sur au moins 99 % du volume cible previsionnel en radiotherapie conformationnelle avec modulation d’intensite (RCMI) de type Rapidarc®. Un traitement preventif substitutif par hydrocortisone a ete prescrit en cas d’irradiation bilaterale. Resultats et analyse statistique Le suivi moyen etait de 11,4 mois. Les taux de controle local, de survie globale et de survie sans progression etaient respectivement de 90 %, 100 % et 72,9 % a 6 mois et 90 %, 80 % et 54,7 % a 1 an. Le traitement systemique a ete modifie chez deux patients avec une duree moyenne de 15,6 mois. Le delai median de changement de traitement systemique apres la radiotherapie stereotaxique hypofractionnee etait estime a 20,5 mois. Aucune toxicite de grade 3 ou plus n’a ete observee. Conclusion Dans notre serie, la radiotherapie stereotaxique hypofractionnee des oligometastases surrenaliennes est une technique bien toleree et efficace (90 % de taux de controle local a 1 an) permettant de garder le meme traitement systemique pendant une duree mediane moyenne superieure a 1,5 an.

Introduction et but de l’etude Il existe un consensus depuis 2004 pour proposer une dose de 12 a 13 Gy sur l’isodose d’enveloppe afin de limiter les taux de complication pour les radiochirurgies stereotaxiques des schwannomes vestibulaires. L’objectif etait d’evaluer retrospectivement l’efficacite et la toxicite de la radiochirurgie stereotaxique des schwannomes vestibulaires traites sur accelerateur lineaire avec differentes doses d’enveloppe. Materiel et methodes De 1995 a 2019, chez 97 patients, des schwannomes vestibulaires de stade 1 (1 %), 2 (56 %), 3 (21,5 %) et 4 (21,5 %) ont ete traites par irradiation stereotaxique par accelerateur lineaire avec cadre invasif avant fevrier 2014 (62 %), puis sans cadre (38 %). La dose mediane prescrite en enveloppe etait de 14 Gy (extremes : 12-16 Gy) avant 2006, puis de 11 Gy pour tous les patients (61)(protocole de desescalade institutionnel). Le volume moyen tumoral etait 1,96 cm3 (extremes : 0,1–13,2 cm3). Le suivi median etait 8,2 ans. Resultats et analyse statistique Pour les 97 patients pris en charge, le taux de controle local etait de 100 %, 98,4 % et 95,6 % respectivement a 2, 5 et 10 ans. Le taux de controle local pour une dose d’enveloppe de 11 Gy etait de 100 % a 10 ans contre 100 %, 97 % et 94 % respectivement a 2, 5 et 10 ans pour la dose d’enveloppe d’au moins 12 Gy (p = 0,35). Une augmentation transitoire tumorale pouvait etre observee jusqu’a 2 ans (12,4 % sur l’IRM a 6 mois et 3,1 % a 1 an). A 5 ans, le taux de toxicite etait de 5,5 % sur le nerf facial (1,7 % pour une dose d’enveloppe de 11 Gy contre 11,2 % pour 12 Gy avec p = 0,11, contre 11,2 % si la dose d’enveloppe etait superieure ou egale a 12 Gy avec p = 0,05) et 8,6 % sur le nerf trijumeau (3,7 % si la dose d’enveloppe etait de 11 Gy contre 0 % pour 12 Gy avec p = 0,51, contre 14,2 % pour une dose d’enveloppe superieure ou egale a 12 Gy avec p = 0,11). Le taux de baisse de l’audition chez les patients ayant initialement une audition utile etait 41,4 % a 5 ans (42,3 % si la dose d’enveloppe etait de 11 Gy contre 44,4 % si elle etait superieure ou egale a 12 Gy, p = 0,71). Conclusion Une diminution de la dose d’enveloppe a 11 Gy pour les radiochirurgies stereotaxiques de schwannomes vestibulaires permet de conserver le meme taux de controle local (100 % a 10 ans) mais avec une reduction du taux de toxicite.

Introduction et but de l’etude Historiquement, les premiers calculs de dose aux nodules pulmonaires traites par irradiation stereotaxique utilisaient l’algorithme Pencil Beam. Aujourd’hui, l’algorithme Monte Carlo permet une meilleure evaluation de la dose en prenant en compte les heterogeneites pulmonaires. L’objectif de l’etude etait de quantifier les ecarts de calcul de dose entre ces deux algorithmes pour verifier si la dose prescrite doit toujours etre la meme. Materiel et methodes Les dosimetries planifiees avec Pencil Beam de 84 patients traites de 2012 a 2015 pour radiotherapie stereotaxique pulmonaire en arctherapie dynamique coplanaire ont ete recalculees avec l’algorithme Monte Carlo. Des cancers primitifs (69 %) et des metastases (31 %) ont ete inclus. La dose mediane prescrite respectivement sur les cancers primitifs et les metastases etait de 54 Gy et 45 Gy en trois fractions sur l’isodose 80 %. Les doses ont ete relevees dans le volume cible previsionnel. Le volume cible previsionnel median etait de 36 cm3 (extremes : 4–131 cm3). La distance mediane entre les nodules et la paroi thoracique etait de 14 mm (extremes : 0–55 mm). Resultats et analyse statistique Par rapport a l’algorithme Monte Carlo, Pencil Beam surestimait significativement la dose delivree dans le volume cible previsionnel de 16 % pour la dose moyenne (61,5 contre 52,9 Gy, p Conclusion Par rapport a l’algorithme Monte Carlo, l’algorithme Pencil Beam surestime la dose moyenne recue dans le volume cible previsionnel. Ces donnees suggerent que la dose prescrite calculee par l’algorithe Monte Carlo pourrait etre diminuee d’au moins 10 %.

Description of the treatment technique of stereotactic lung radiotherapy on Novalis TxFrom October 2012 to December 2015, 100 inoperable pulmonary nodules (62 stage I non-small-cell lung cancer and 38 metastases) of 90 patients with a mean age of 68.2 years (range: 46-89 years) were prospectively treated with dynamic arctherapy on Novalis TxComplete response was observed in 23.8% of cases. Local control rates were 100% and 90.7% respectively at 12 and 24 months, with 96% at 24 months for stage I non-small-cell lung cancer. Overall survival rates of patients with stage I non-small-cell lung cancer were 77.4% and 73.5% at 12 and 24 months (median overall survival was 32 months). Diffusing capacity of the lungs for carbon monoxide corrected for alveolar volume below 40% was significantly associated to a poor prognostic factor on univariate analysis (P=0.00013). At least three deaths were due to an acute respiratory failure, which correspond to about 4.8% of grade 5 radiation pneumonitis. Overall survival rate for metastatic patients were 95.2% and 59.5% respectively at 12 and 24 months (median overall survival was 25 months); 23.3% of grade 2 or less radiation pneumonitis, 7.8% of grade 2 or less radiation dermatitis, 2.2% of asymptomatic ribs fracture and 3.3% of chest pains were observed.Stereotactic lung radiotherapy is an effective treatment for inoperable stage I non-small-cell lung cancer and lung oligometastases of well informed and selected patients. Initial respiratory state, and especially the diffusing capacity of the lungs for carbon monoxide corrected for alveolar volume, seems to be important for tolerance.

Objectif de l’etude Le volume de cerveau recevant plus de 18 Gy (V18) et l’indice de conformite (IC) sont predictifs de radionecrose apres radiotherapie stereotaxique hypofractionnee des volumineuses metastases cerebrales. L’objectif de l’etude etait de comparer les parametres dosimetriques des metastases cerebrales prises en charge par arctherapie dynamique conformationnelle sur Novalis® a ceux obtenus par arctherapie volumetrique avec modulation d’intensite sans et avec arcs non coplanaires. Materiel et methode les dossiers de dix patients pris en charge arctherapie dynamique conformationnelle (quatre a cinq arcs non coplanaires) sur Novalis® pour une metastase de diametre ≤ 25 mm ont ete analyses. Les doses prescrites etaient de 33 Gy a l’isocentre et 23,1 Gy en enveloppe (70 %) en trois fractions (Iplan®). Le volume tumoral macroscopique correspondait a la prise de contraste sur l’IRM ponderee en T1 apres injection de gadolinium. Le volume cible previsionnel correspondait au volume tumoral macroscopique plus 2 mm. Deux plans d’arctherapie volumetrique modulee supplementaires ont ete realises : avec deux arcs coplanaires (VMATc) et avec un arc coplanaire et trois arcs non coplanaires (VMATnc) en prescrivant 33 Gy dans le volume tumoral macroscopique et 23,1 Gy dans le volume cible previsionnel, avec optimisation sur les Normal Tissue Objectives (NTO ; Eclipse®). Resultats Le volume tumoral macroscopique moyen etait de 27 mm (extremes : 25–30 mm). La couverture du volume cible previsionnel sur l’isodose de prescription etait de plus de 99 % pour les trois plans. Les indices de conformite etaient de 0,9 pour les deux plans d’arctherapie volumetrique modulee (0,92 en VMATc ; 0,95 en VMATnc) contre 0,78 en arctherapie dynamique conformationnelle (p Conclusion L’arctherapie volumetrique modulee avec arcs non coplanaires est une technique de radiotherapie stereotaxique hypofractionnee qui donne une excellente couverture du volume cible et ameliore l’indice de conformite et le volume de tissu cerebral sain irradie a fortes (V18) ainsi qu’a faibles doses (V5). C’est devenu la technique de choix pour le traitement des metastases cerebrales de 25 mm ou plus par irradiation stereotaxique hypofractionnee sur Novalis® dans notre institution.

People over the age of 65 are often excluded from participation in oncological clinical trials. However, more than half of patients diagnosed with non-small-cell lung cancer are older than 65 years. Any therapeutic strategy must be discussed in multidisciplinary meetings after adapted geriatric assessment. Patients who benefit from the comprehensive geriatric assessment (CGA) of Balducci and Extermann are those whose G8 screening tool score is less than or equal to 14. Age itself does not contraindicate a curative therapeutic approach. Stereotactic radiotherapy is an alternative to surgery for early stages in elderly patients who are medically inoperable or who refuse surgery, because it significantly increases overall survival. Mostly sequential (rarely concomitant) chemoradiotherapy can be proposed to elderly patients with locally advanced stages in good general state of health. For the others, an exclusive palliative radiotherapy, a single or dual agent of chemotherapy, a targeted drug or best supportive care only may be discussed.

The rate of local failure of stage IIIA-N2 non-small cell lung cancer is 20 to 40%, even if they are managed with surgery and adjuvant chemotherapy. Postoperative radiotherapy improves local control, but its benefit on global survival remains to be demonstrated. Considered for many years as an adjuvant treatment option for pN2 cancers, it continues nevertheless to be deemed too toxic. What is the current status of postoperative radiotherapy? The Lung Adjuvant Radiotherapy Trial (Lung ART) phase III trial should give us a definitive, objective response on global survival, but inclusion of patients is difficult. The results are consequently delayed. The aim of this review is to show all the results about efficacy and tolerance of postoperative radiotherapy and to define the target volume and dose to prescribe.

Prostate cancer is the most frequent cancer among European males with a high survival rate. The economic impact of treatments and follow-up are significant. The objectives of the follow-up after prostate radiotherapy is multiple: diagnosis and treatment of side-effects, early detection of biochemical recurrence, with the aim of proposing a second local treatment to improve quality of life or overall survival and feedback of the treatment results to better inform patients at the beginning of the disease. This article reports incidence of main side-effects (digestive, urinary and sexual) with their treatments and guidelines for clinical and biological follow-up with strategies of imaging studies and salvage treatments.

Objectif de l’etude Aucun seuil de volume expire maximal en une seconde (VEMS) ou capacite de diffusion du monoxyde de carbone (DLCO) ne contre-indique une radiotherapie stereotaxique hypofractionnee pulmonaire. L’objectif etait d’evaluer prospectivement les facteurs pronostiques chez des patients traites par irradiation stereotaxique hypofractionnee pour un cancer bronchique non a petites cellules localisees inoperables. Materiel et methode D’octobre 2012 a decembre 2015 ont ete traites sur NovalisTx ® avec recalage Exatrac ® 62 patients inoperables atteints de cancer bronchique non a petites cellules de stade T1T2N0M0 de moins de 5 cm. L’âge moyen etait 69,5 ans (47–89). Les moyennes respectives des VEMS, DLCO et DLCO/VA etaient 62 % (20–126), 47 % (8–82) et 61 % (11–114). Les volumes tumoral macroscopiques (GTV) et volume cible previsionnel (PTV) moyens etaient 7 cm 3 (0,2–31) et 50 cm 3 (6–131). Quatre-vingt dix pour cent des nodules etaient peripheriques et la moitie sans histologie. Les doses prescrites sur l’isodose 80 % etaient de 54 Gy en trois fractions ou 45–50 Gy en cinq fractions, soit une dose biologique efficace pour un rapport α / β de 10 Gy (BED10) moyenne de 159,8 Gy (80–175,5). Le suivi moyen etait 12,1 mois (0,6–34,9). Resultats Les taux de controle local et de survie globale etaient respectivement 96 et 73 % a 24 mois. Aucun deces n’etait lie au cancer pulmonaire. En analyse unifactorielle, les facteurs pronostiques de survie globale etaient un rapport DLCO/VA de moins de 40 % ( p = 0,00013), un PTV ≥ 64 cm 3 ( p = 0,00022), une D2 cm (dose recue a 2 cm du PTV) > 40 Gy ( p = 0,090) et une pneumopathie de grade 2 a un mois ( p = 0,0013). En analyse multivariee, les deux facteurs pronostiques independants etaient un rapport DLCO/VA ≥ 40 ou 60 % (HR [ Hazard Ratio ] = 0,21, IC95 % [intervalle de confiance a 95 %] = 0,05–0,92) et une dose moyenne au poumon homolateral (BED3, dose biologique efficace pour un rapport α/β de 10 Gy) > 75 Gy (HR = 3,90, IC95 % = 1,03–14,74). Chez les patients avec un rapport DLCO/VA ≤ 60 %, une dose moyenne au poumon homolateral (BED3) ≤ 55 Gy etait significativement pronostique de la survie globale (80 % contre 40 % a 24 mois, p Conclusion Le rapport DLCO/VA et la dose moyenne au poumon homolateral doivent etre pris en compte en radiotherapie stereotaxique hypofractionnee thoracique.

Resume Les glandes surrenales sont frequemment le siege de metastases. Elles representent le quatrieme site metastatique des tumeurs solides. Un interet pour les traitements locaux des oligometastases a ete montre en termes de la survie sans recidive, de qualite de vie et potentiellement de survie globale. La chirurgie reste le traitement de reference des oligometastases surrenaliennes car elle offre de tres bons resultats et un recul suffisant. Cependant, la radiotherapie stereotaxique semble etre comparable a la chirurgie et pourrait etre proposee en alternative, particulierement aux patients âges, fragiles, inoperables et pour ceux dont le traitement systemique ne doit pas etre suspendu trop longtemps. L’objectif de cet article est de faire une mise au point sur les etudes publiees a ce jour sur la radiotherapie stereotaxique des metastases surrenaliennes et proposer un protocole de traitement.

Objectifs La delineation du volume tumoral macroscopique sur une scanographie peut necessiter le recalage d’une tomographie par emission de positons (TEP). En l’absence de consensus valide, l’objectif de l’etude etait de comparer les differentes methodes de segmentation par seuillage des TEP pour obtenir un volume se rapprochant le plus du volume tumoral macroscopique metabolique clinique dans l’optique d’une application en routine en radiotherapie ORL. Materiel et methodes Six spheres d’un diametre different (de 10 a 37 mm) et le corps d’un fantome NEMA IEC body Phantom setTM ont ete remplis par une quantite equivalente de (18F)-fluorodesoxyglucose (FDG). Differents niveaux de rapport signal/bruit de fond ont ete ainsi calcules. L’imagerie des spheres a ete acquise sur une TEP-scanographie de type Discovery ST™. Le volume des spheres a ete segmente par une methode visuelle, quatre methodes de seuillage fixe (standard uptake value [SUV] de 2,5, 40 %, 50 % et 70 %) et la methode de seuillage adaptatif de Daisne basee sur le bruit de fond environnant (SBR). Les differents diametres, volumes et concordances obtenus par chacune des methodes de segmentation ont ete compares aux donnees reelles scanographiques. Resultats Pour les diametres des spheres, aucune methode de segmentation ne montrait de difference significative entre la TEP et la scanographie, sauf pour la SUV de 70 %. L’analyse de variance des volumes n’a pas montre de variabilite entre les methodes de segmentation globale statistiquement significative (F = 0,545 Conclusion Les methodes de seuillage adaptatif SBR et de SUV de 40 % semblent etre les meilleures methodes de segmentation pour obtenir le volume tumoral macroscopique metabolique le plus proche de la clinique. En routine clinique, le recalage de la TEP en radiotherapie ORL dans le service est desormais realise a partir de ces deux methodes de segmentation.

Objectif Etudier prospectivement les facteurs predictifs d’efficacite et de toxicite de la radiotherapie stereotaxique pulmonaire sur NovalisTx ® . Materiels et methodes De 2012 a 2015, 100 nodules pulmonaires (62 cancers primitifs localises et 38 metastases) chez 90 patients ont ete traites par un NovalisTx ® . L’âge moyen etait 68,2 ans. Les moyennes respectives des volume expiratoire maximal par seconde (VEMS), diffusion libre du CO (DLCO) et volume alveolaire (DLCO/VA) etaient 71 %, 58 % et 71 %. Les volumes tumoraux macroscopiques (GTV) et cibles previsionnels (PTV) moyens etaient de 7 cm 3 et 39 cm 3 . Les doses de prescription sur l’isodose 80 % etaient respectivement de 54 Gy en trois fractions, 50 Gy en cinq fractions et 45 Gy en trois fractions pour les nodules primitifs peripheriques, primitifs centraux et metastatiques (ou 40–45 Gy en cinq fractions selon les contraintes aux organes a risque). Le suivi moyen etait 12,6 mois. Resultats Un quart des nodules etait en reponse complete scanographique. Le taux de controle local etait respectivement 100 % et 90,7 % a 1 et 2 ans, tous nodules confondus. En analyse unifactorielle, les facteurs predictifs de controle local etaient GTV (moins de 17 cm 3 , p = 0,00009) et la dose biologique efficace (BED10 min) recue par le PTV (plus de 100 Gy, p = 0,043). Le caractere primitif ou metastatique n’etait pas significatif. Le taux de pneumopathie de grade 2 etait 30,9 % et correle avec un rapport DLCO/VA ≤ 60 % (47,8 % contre 23,5 %, Risque Relatif = 2,03 (0,98–4,21), p = 0,056). Il y a eu 3,3 % de douleurs costales, toutes survenues pour une BED8 maximale a la paroi homolaterale ≥ 250 Gy (11 % contre 0 %, p = 0,03) et apres en moyenne 7 mois. Il a ete constate sept epithelites de grade ≤ 2 (7,8 %), en moyenne a 3 mois. Conclusion Le taux de controle local est lie au volume des nodules (moins de 17 cm 3 , soit environ 3 cm) et a la dose delivree au PTV (BED10 min de plus de 100 Gy). La toxicite de grade 2 semble principalement liee aux fonctions respiratoires et aux doses parietales recues.

People over the age of 65 are often excluded from participation in oncological clinical trials. However, more than half of patients diagnosed with non-small-cell lung cancer are older than 65 years. Any therapeutic strategy must be discussed in multidisciplinary meetings after adapted geriatric assessment. Patients who benefit from the comprehensive geriatric assessment (CGA) of Balducci and Extermann are those whose G8 screening tool score is less than or equal to 14. Age itself does not contraindicate a curative therapeutic approach. Stereotactic radiotherapy is an alternative to surgery for early stages in elderly patients who are medically inoperable or who refuse surgery, because it significantly increases overall survival. Mostly sequential (rarely concomitant) chemoradiotherapy can be proposed to elderly patients with locally advanced stages in good general state of health. For the others, an exclusive palliative radiotherapy, a single or dual agent of chemotherapy, a targeted drug or best supportive care only may be discussed.

Objectifs L’objectif etait d’evaluer prospectivement les effets doses/volumes de la radiotherapie stereotaxique hypofractionnee pulmonaire. Patients et methodes De 2012 a 2014, 58 nodules pulmonaires, dont 52 % primitifs et 86 % peripheriques (chez 54 patients), ont ete traites par irradiation stereotaxiques sur un accelerateur Novalis Tx® par une technique d’arctherapie dynamique coplanaire. Les doses moyennes prescrites sur l’isodose 80 % etaient de 50,8 Gy (42-54) en trois fractions ou 46,1 Gy (36-60) en cinq fractions. La duree moyenne de suivi etait de 11,3 mois. Les populations recevant le traitement en trois et cinq fractions etaient comparables en termes de volume, d’âge, d’etat general et respiratoire (epreuves fonctionnelles respiratoires et dyspnee). Les volumes tumoraux macroscopiques et cibles previsionnels moyens etaient respectivement de 7,2 cm 3 (0,2–31,4) et 40,2 cm 3 (3,9–131). Resultats Tous nodules confondus, les taux de controle local etaient respectivement 90 % et 77 % a 12 et 24 mois. Les facteurs predictifs etaient un traitement en trois fractions (93 contre 58 % a 24 mois, p = 0,003) et le volume tumoral macroscopique ( p = 0,006). Les probabilites de survie globale des patients atteints de cancer primitifs a 6 et 24 mois etaient respectivement de 89 % et 75 %. Les facteurs pronostiques etaient un traitement en trois fractions (88 contre 43 % a 24 mois, p = 0,01), un volume cible previsionnel plus petit (seuil a 55 cm 3 , p = 0,016) et une dose equivalente biologique (BED) avec un rapport α/β egal a 10 plus forte (seuil a 150 Gy a la moyenne du volume cible previsionnel, p = 0,003). Les taux de pneumopathie de grade 2 selon la Common Terminology Criteria for Adverse Events (CTCAE) a 1, 6 et 12 mois etaient respectivement de 11 %, 24 % et 35 %. Les facteurs predictifs etaient un volume expiratoire maximal par seconde (VEMS) plus bas (46 % si moins de 65 % contre 9,7 % a 12 mois ; p = 0,018), une capacite de diffusion du monoxyde de carbone (DLCO) plus basse (60 % si moins de 37 % contre 16 % a 12 mois ; p = 0,027) et un traitement en trois fractions (44 % contre 14 % a 12 mois, p = 0,024). Les BED ( biological effective dose ) moyennes dans le poumon homolateral etaient plus elevees chez les patients traites en trois fractions (18,2 Gy contre 12,8 Gy, p = 0,017). Conclusion Un VEMS de moins de 5 % et une DLCO de moins de 37 % doivent faire majorer les contraintes pulmonaires, notamment de la dose moyenne dans le poumon homolateral. Une BED moyenne dans le volume cible previsionnel de plus de 150 Gy etait associee a une meilleure probabilite de survie globale dans le cas des cancers primitifs.

Objectif Evaluation clinique prospective monocentrique des dossiers de patients traites par irradiation stereotaxique pour une tumeur pulmonaire de stade I inoperable ou des metastases a croissance lente avec tumeur primitive controlee. Patients et methodes D’octobre 2012 a fevrier 2014, 29 patients ont recu une radiotherapie stereotaxique thoracique pour 22 nodules primitifs de stade I et 10 metastatiques avec un accelerateur lineaire de type Novalis TX ® . Une acquisition dosimetrique quadridimensionnelle a ete realisee pour les 17 derniers patients. L’âge moyen des patients etait de 66,5 ans (50–84). Huit patients souffraient d’une dyspnee de grade 2 ou plus avant le traitement. Les volumes tumoraux macroscopiques et les volumes cibles previsionnels moyens etaient respectivement 8,3 cm 3 (0,2–31,4 ; mediane = 5,0) et 51 cm 3 (4,0–131,0). La dose variait selon le caractere primitif, secondaire, central ou peripherique du nodule. La dose moyenne delivree etait 62,7 Gy (50–75) a l’isocentre en trois ou cinq fractions avec une dose moyenne par fraction de 17,6 Gy (10–22,5). L’etalement moyen etait de 9,5 jours (3–18). Un suivi clinique et scanographique a ete effectue a 1 mois, puis tous les trois mois. Resultats Le suivi median etait de 7,4 mois. La toxicite selon la classification CTCAE ( Common Terminology Criteria for Adverse Events ) etait de grade 2 ou plus pour 26 patients et de 5 pour deux patients, dont une insuffisance respiratoire aigue 15 jours apres la fin du traitement chez un patient avec un volume expiratoire maximal par seconde (VEMS) de 21 % et une diffusion libre du monoxyde de carbone DLCO) de 14 %. Une reponse objective scanographique a ete observee a 3 mois dans 19 cas (61,3 %), dont neuf avec une diminution superieure a 50 %. A 1 an, les probabilites de survies globale et sans recidive etaient respectivement de 69,4 % et 53,9 % avec un taux de controle local de 85,5 %. Conclusion Les resultats preliminaires de cette etude sur la radiotherapie stereotaxique thoracique sont encourageants. La toxicite respiratoire est a prendre en compte en selectionnant les patients plus rigoureusement. L’evaluation a plus long terme avec plus de patients se poursuit.