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Resume Objectif Evaluer l’apport de l’imagerie remnographique (IRM) dans la planification dosimetrique d’une radiotherapie de prostate. Patients et methodes Sur dix patients consecutifs traites pour un adenocarcinome prostatique de faible risque, un recalage etait effectue entre images IRM et les coupes scannographiques (TDM) obtenues au moment de la simulation. Le volume prostatique etait delinee par plusieurs medecins differents, sur le TDM et sur le recalage. Pour chaque plan de traitement, nous avons evalue l’impact de l’IRM sur le volume previsionnel de traitement (PTV) et sa position, la variabilite de la delineation entre medecins, ainsi que sur la dose aux organes a risque pour une dose prescrite de 74 Gy en 37 fractions de 2 Gy au PTV. Resultats Les volumes des PTV prostate delinees sur TDM etaient en moyenne de 1,15 [ecart-type 3,71] fois plus gros que ceux delinees sur IRM. L’apex prostatique etait identifie plus caudalement sur le scanner, en moyenne de 4,6 mm [ecart-type 2,87]. Le bord posterieur de la prostate etait determine en moyenne 4 mm plus en arriere sur le scanner. L’IRM permettait une diminution de la variabilite de la delineation entre medecins. Les variations interindividuelles moyennes de la position de l’apex passaient de 6,8 mm (TDM) a 3,3 mm (IRM). La dose rectale moyenne etait inferieure de 8 % a la dose rectale moyenne obtenue avec les plans de traitement obtenus a partir du TDM. Conclusion Le recalage TDM/IRM a ameliore la precision, diminue la variabilite de la delineation et permet d’epargner une partie du rectum. Il reste a determiner le benefice clinique d’une telle strategie.

Objectif de l’etude La repletion vesicale est un element majeur de la prevention de la toxicite urinaire lors d’une radiotherapie prostatique. Cette etude avait pour objectif d’evaluer de facon mono-institutionnelle les recommandations (ecrites et orales) de repletion vesicale donnees systematiquement aux patients. Materiel et methode Les 280 patients atteints d’un cancer de la prostate traite avec intention curative par irradiation en 2015 ont ete interroges apres la fin de leur traitement. Les donnees de toxicite urinaire aigue ont ete recueillies (Common Terminology Criteria for Adverse Events [CTCAE] v4.0). Resultats Sur les 150 patients ayant accepte de participer a l’etude, 86 % se souvenaient avoir recu les recommandations (n = 129), 56,6 % disaient avoir compris l’interet du conseil (n = 73), 77,5 % rapportaient avoir toujours reussi a appliquer les recommandations (n = 100), 7 % des patients rapportaient avoir reussi a appliquer ces consignes lors de moins de 75 % des seances (n = 9). La repletion vesicale etait percue comme une contrainte pour 65,8 % des patients (n = 85) ; 81 patients (54 %) ont beneficie d’une tomographie conique en cours de traitement, permettant d’apprecier la repletion vesicale, soit 821 tomographies coniques. Douze tomographies coniques (1,4 %) ont ete refaites avant la seance du fait d’un remplissage vesical juge insuffisant par les manipulateurs, 49 % ont ete invalides a posteriori par l’oncologue radiotherapeute du fait d’un remplissage vesical juge insuffisant. Une toxicite urinaire aigue de grade 1 et 2 a ete rapportee chez respectivement 36 % (n = 54) et 16 % des patients (n = 24). Aucune toxicite de grade 3–5 n’a ete rapportee. Les patients ne se souvenant pas d’avoir recu une information concernant le remplissage vesical n’avait significativement pas plus de toxicite urinaire aigue de grade 2 (p = 0,9) ou de grade 1–2 (p = 0,3). Conclusion La delivrance d’une information orale et ecrite systematique avant une radiotherapie de prostate semble effective pour la reproductibilite de la repletion vesicale. La toxicite tardive sera etudiee prospectivement chez ces patients.

Objectif de l’etude La radiotherapie hypofractionnee moderee et la radiotherapie stereotaxique sont deux approches prometteuses pour le cancer de la prostate. Une etude de phase II randomisee a compare les profils de tolerance de ces deux schemas d’irradiation hypofractionnee. Les premiers resultats en termes de toxicite aigue sont rapportes. Materiel et methode Entre 2015 et 2016, 96 patients ont ete randomises pour recevoir 20 fractions de 3,1 Gy (62 Gy) (bras A) ou 5 de 7,5 Gy (37,5 Gy) (bras B) pour un cancer de prostate de risque faible ou intermediaire. Une injection transperineale de 3–10 cm3 d’acide hyaluronique a ete realisee, ainsi que l’implantation de trois grains d’or intraprostatiques. L’hormonotherapie n’etait pas acceptee. La toxicite aigue a ete evaluee selon la classification Common Terminology Criteria for Adverse Events (CTCAE) v4 et la tolerance de l’injection d’acide hyaluronique par l’echelle visuelle analogique (EVA). Les resultats sont rapportes pour les premiers 51 patients. Les donnees finales sur 96 patients seront disponibles au moment du congres annuel de la Societe francaise de radiotherapie oncologique (SFRO ; Paris, octobre 2017). Resultats L’injection d’acide hyaluronique a ete tres bien toleree, avec un score moyen sur l’EVA de 2,63 (standard deviation [sd] : 2,75) pendant l’injection et 0,55 (SD : 1,03) a 30 minutes. Aucune toxicite digestive aigue de grade 3–4 n’a ete observee. Les taux de toxicite digestive de grade 2 etaient equivalents entre les deux bras (18,5 % contre 18,2 %). Deux patients ont souffert d’une toxicite urinaire aigue de grade 3 (une dysurie dans le bras A et une pollakiurie dans le bras B). Aucune toxicite urinaire aigue de grade 4 n’a ete notee. Les taux de toxicite urinaire aigue de grade 2 etaient comparables entre les deux bras (42,3 % contre 42,9 %). Conclusion Les deux schemas sont bien toleres, avec une toxicite urinaire aigue de grade 3 dans chaque bras et aucune toxicite rectale de grade 3. Les taux de toxicite urinaire ou rectale de grade 2 etaient comparables entre les deux schemas. La toxicite aigue rectale semblait bien controlee par l’acide hyaluronique dans les deux bras.

Resume La radiotherapie normalement fractionnee est le standard de la prise en charge adjuvante des cancers du sein operables traites par tumorectomie. Cependant, de nombreuses patientes âgees ne peuvent beneficier de cette strategie, soit qu’elles souffrent de maladies ne permettant pas l’anesthesie generale, soit que la tumeur soit inoperable. Plusieurs protocoles de radiotherapie exclusive ont ete decrits dans la litterature, associant souvent radiotherapie hypofractionnee et hormonotherapie. Nous rapportons le cas d’une patiente traitee par l’association exclusive de radiotherapie et d’hormones et dressons l’etat de l’art en matiere de schemas de radiotherapie hypofractionnee dans la prise en charge des cancers du sein de la personne âgee. Alors que l’analyse de la litterature montre que la radiotherapie hypofractionnee ne compromet pas le resultat carcinologique ou cosmetique, il n’existe pas de donnee prospective evaluant la place de la radiotherapie comme traitement exclusif des patientes les plus âgees. Cette strategie merite d’etre evaluee par un essai randomise.

Radiation therapy has a major role in the management of infiltrative breast cancers. However, there is no consensus for the prophylactic treatment of the internal mammary chain (IMC), with strategies that show strong differences according to centers and physicians. Indications for internal mammary chain radiotherapy are debated, since this treatment significantly increases the dose delivered to the heart and leads to potential technical difficulties. Important prospective data recently suggested that internal mammary chain radiotherapy would not be necessary, even in cases of internal or central tumor locations, or in patients with positive axillary lymph nodes. Although these data warrant confirmation by two other prospective trials, there is evidence that the indications for internal mammary chain radiotherapy should be careful and that high quality techniques should be used for decreasing the dose delivered to the heart. This review of literature presents the state of art on the radiotherapy of internal mammary chain, with special focus on the indications, techniques, and potential toxicity.

Objectif de l’etude L’objectif de cette etude etait d’evaluer le taux de sterilisation des pieces operatoires et le taux de survie globale a 5 ans des patientes traitees dans notre institut pour un cancer du col uterin localement evolue. Patientes et methodes Toutes les patientes traitees consecutivement pour un cancer du col uterin localement evolue a l’institut de cancerologie Lucien-Neuwirth de Saint-Etienne entre le 1 er janvier 2004 et le 31 decembre 2014 ont ete incluses. Resultats Parmi les 203 patientes traitees pour un cancer du col uterin pendant cette periode, 100 etaient atteintes d’une tumeur localement evoluee, dix de stade IB2 (10 %), 24 de stade IIA (24 %), 48 de stade IIB (48 %), six de stade IIIA (6 %), 12 de stade IIIB (12 %), dont 78 % de carcinomes epidermoides et 14 % d’adenocarcinomes, 33 % avec un envahissement ganglionnaire pelvien. Quarante patientes ont recu une chimioradiotherapie concomitante preoperatoire optimale (avec au moins cinq cures de chimiotherapie), puis curietherapie uterovaginale. La radiotherapie etait une par RCMI ou une arctherapie dans 37,7 % des cas. La chimiotherapie concomitante etait du cisplatine pour 78,8 % des patientes. La curietherapie a ete delivree a debit pulse dans 95,8 % des cas, planifiee a l’aide d’une scanographie de dosimetrie, mais non optimisee par IRM. L’etalement median du traitement etait de 56 jours. Le taux de sterilisation des pieces operatoires etait de 51,4 %. Le taux de reponse histologique partielle etait de 31,9 %. Le suivi moyen etait de 3,3 ans. Le taux de recidive locale etait de 15 %. Le taux de survie globale a 5 ans etait de 49,4 %, celui de survie sans recidive locale a 5 ans de 47,5 %. Conclusion Malgre un taux correct de sterilisation des pieces operatoires, le taux de survie global a 5 ans demeure decevant.

A regional cancer network has been set up in the Rhone-Alpes region in France. The aim of the project is to improve the quality of care and to rationalize prescriptions in the network. In this network, we assessed the impact of the implementation of a clinical practice guidelines project by assessing the conformity of practice with the guidelines and comparing this with the conformity in an external matched control group from another French region without a regional cancer network. Four hospitals (private and public) accepted to assess the impact of the clinical practice guidelines on the management of breast and colon cancer in the experimental group and three hospitals (private and public) in the control group. In 1994 and 1996, women with non-metastatic breast cancer (282 and 346 patients in the experimental group, 194 and 172 patients in the control group, respectively) and all new patients with colon cancer (95 and 94 patients in the experimental group, and 89 and 118 patients in the control group, respectively) were selected. A controlled ‘before-after’ study, using institutional medical records of patients with breast and colon cancer. The medical decisions concerning the patients were analyzed to assess their compliance with the clinical practice guidelines. When medical decisions were judged to be non-compliant, we verified if they were based on scientific evidence in a published article, if they were not, the medical decision was classified as having ‘no convincing supporting scientific evidence’ The compliance rates were significantly higher in 1996 than in 1994 in the experimental group; 36% (126 out of 346) vs 12% (34 out of 282) and 46% (56 out of 123) vs 14% (14 out of 103) (P

Objectif de l’etude Cette etude avait pour objectif principal d’evaluer si une radiotherapie classique de huit semaines etait aussi efficace qu’une radiotherapie hypofractionnee de quatre semaines, sans majorer la toxicite, chez des patients atteints de cancer de prostate de risque intermediaire. Materiel et methode Des patients atteints de cancer de prostate de risque intermediaire ont ete randomises entre une radiotherapie classique de 78 Gy en 39 fractions et 8 semaines et une radiotherapie hypofractionnee de 60 Gy en 20 fractions et quatre semaines, avec guidage par l’image quotidien obligatoire. Chaque plan de radiotherapie a ete revu en temps reel de facon centralisee (respect contraintes de dose et volume comprenant prostate et ou non base des vesicules seminales). Le critere principal etait la rechute biochimique ou clinique definie par : une rechute biochimique (nadir + 2 ng/mL), le debut d’une hormonotherapie, une rechute locale ou a distance ou deces. L’hypothese de non-inferiorite etait que le taux de rechute biochimique ou clinique a 5 ans apres radiotherapie hypofractionnee n’etait pas superieur de 7,5 % a celui apres radiotherapie classique (risque relatif maximal 1,32 ; beta = 85 %, alpha = 5 % unilateral). Resultats Un total de 1206 patients d’âge moyen de 71 ans [48–88 ans], suivis en mediane 6 ans, ont ete inclus au Canada, en Australie et en France (radiotherapie hypofractionnee : 608 patients ; radiotherapie classique : 598 patients). A ce jour, 164 patients ont ete atteints d’une rechute biochimique ou clinique apres radiotherapie hypofractionnee contre 173 apres radiotherapie classique (a 5 ans, 21 % de rechutes biochimiques ou cliniques dans les deux bras ; hazard ratio : 0,96 [intervalle de confiance a 90 % : 0,80–1,15]). Soixante-quinze patients sont decedes dans chaque groupe. La toxicite aigue genito-urinaire et gastro-intestinale de grade 3 ou plus selon la classification du Radiation Therapy Oncology group (RTOG) etait comparable. Cependant, la toxicite tardive favorisait le bras radiotherapie hypofractionnee (3,5 % contre 5,4 % ; difference = −1,9 % ; intervalle de confiance a 95 %, −4,3 a 0,43 %). Conclusion L’efficacite de la radiotherapie hypofractionnee des cancers de prostate de risque intermediaire n’est pas inferieure a la celle de la radiotherapie classique, sans majoration de la toxicite aigue ni tardive.

Objectif de l’etude L’essai de phase 3 ACCORD 12 a teste l’addition d’oxaliplatine dans le traitement neodjuvant des cancers du rectum localement evolues. Les taux de reponse histologique complete n’etaient pas differents entre les bras testes. L’objectif de l’etude est de decrire les resultats de survies apres un suivi de 5 ans. Materiel et methode Les criteres d’inclusion un adenocarcinome rectal T3–T4 Nx M0 ou T2 Nx du bas rectum anterieur. Le bras experimental a modifie la dose de radiotherapie : 50 Gy en 25 seances sur cinq semaines et la chimiotherapie avec l’adjonction d’oxaliplatine (50 mg/m2/semaine). La capecitabine, a la dose de 1600 mg/m2/jour (les jours de radiotherapie), a ete substituee au 5-fluoro-uracile. Dans le bras controle, il etait delivre 45 Gy en 25 seances avec les memes doses de capecitabine. Resultat Entre novembre 2005 et juillet 2008, 598 patients ont ete randomises ; l’âge median etait de 63 ans, la sex-ratio de deux hommes pour une femme. Avec un suivi median de 60,2 mois, il n’y avait pas de differences en termes de survie sans recidive (p = 0,2), de survie globale (p = 0,056) ni de survie specifique (p = 0,19) ; la tendance observee en survie globale etait liee a un nombre plus important de patients âges dans le bras standard ; l’âge ressortait comme facteur pronostique independant de survie globale (p Conclusion L’ajout d’oxaliplatine dans la prise en charge neoadjuvante des adenocarcinomes du rectum ne permet pas d’ameliorer les resultats de survie a 5 ans. D’autres essais sont en cours pour determiner si l’oxaliplatine apporte un gain de maniere sequentiel (PRODIGE 23, addition de FOLFIRINOX, 5-fluoro-uracile-acide folinique, irinotecan et oxaliplatine) et d’autres pour augmenter les taux de reponse clinique complete afin d’augmenter le taux de chirurgie conservatrice (OPERA, addition de contact therapie).

Radiation therapy plays an essential role in the treatment of invasive breast cancer. However, prophylactic treatment of supra- and infraclavicular lymph nodes is not consensual, with different treatment depending on the centres and practitioners. Clinical indications for radiotherapy of the supra- and infraclavicular lymph nodes are often the subject of a consensus. Nevertheless, radiotherapy induces some toxicity. Various techniques have been developed. To date, conformal radiotherapy allows an accurate assessment of doses to target volumes and organs at risk, but at the cost of a sometime complex delineation. This article reviews the literature on radiation of supra- and infraclavicular lymph nodes, with a special focus on technical aspects in delineation and its potential toxicity.

To assess the benefits of magnetic resonance imaging (MRI) in the dosimetric treatment planning for prostate radiotherapy.Ten consecutive patients have been enrolled. They were treated for a low risk prostate adenocarcinoma. A rigid superimposition was performed between MRI and scan slides obtained at time of virtual simulation, then prostate volume was delineated by four to five physicians, on TDM slides and on MRI/TDM superimposition. For each treatment plan, we assessed the impact of MRI in terms of planned treatment volume (PTV) position, individual variability of prostate delineation and doses delivered to the critical organs. The prescribed dose was 74 Gy in 37 fractions to the PTV.PTV delineated on TDM (V(TDM)) were 1.15 (SD 3.71) larger than volumes delineated on MRI. Prostate apex was 4.6 mm (SD 2.87) lower on TDM than on MRI. Posterior limit of the prostate was in mean 4 mm more posterior on TDM. The variability between physicians in terms of prostate delineation was lower using MRI. For apex, these variations were 6.8 mm using TDM, versus 3.3 mm using MRI. Mean rectal dose was 8 % lower with MRI, compared to delineation using TDM.Superimposition TDM/MRI improves accuracy, decreases delineation variability, and allows to spare anterior part of the rectum from irradiation. It remains unknown whether this strategy translates into clinical benefit.

Twenty-four patients with T1 or T2 (17 T1 N0, 7 T2 N0 not exceeding 3 cm) epidermoid carcinomas from the middle third of the mobile tongue benefit from brachytherapy with "cavaliers-legos" consisting of guide-gutters that are inserted in a rigid support (legos) and covered with a lead plate. Several advantages can be advocated with this technique: easy implantation even with local anaesthetic, no risk of bleeding, good parallelism between Iridium wires, protection of the mandible with the lead plate. Local control was achieved in 22/24 patients (92%). Four patients (16%) developed soft tissue necrosis but only one required surgical intervention and no mandibular necrosis was seen.

Normofractionated radiotherapy is standard for adjuvant management of patients treated with breast conservative surgery for breast cancer. However, many elderly patients are not eligible to such strategy, either because of concurrent diseases, or because the tumor is inoperable. Several protocols of exclusive radiotherapy have been reported in the literature, frequently using hypofractionated radiotherapy and endocrine therapy. We report a case of a patient treated with exclusive endocrine and radiotherapy and address the state of the art on hypofractionated schemes for the management of elderly breast cancer patients. While hypofractionated radiotherapy does not compromise the oncologic or cosmetic outcome, there is no prospective data that assesses the place of radiotherapy for the exclusive treatment of elderly patients. This strategy should be further assessed in clinical randomized trial.

International audience; BACKGROUND: This study evaluates the relation of the early oestrogen-regulated gene gabarapl1 to cellular growth and its prognostic significance in breast adenocarcinoma. METHODS: First, the relation between GABARAPL1 expression and MCF-7 growth rate was analysed. Thereafter, by performing macroarray and reverse transcriptase quantitative-polymerase chain reaction (RT-qPCR) experiments, gabarapl1 expression was quantified in several histological breast tumour types and in a retrospective cohort of 265 breast cancers. RESULTS: GABARAPL1 overexpression inhibited MCF-7 growth rate and gabarapl1 expression was downregulated in breast tumours. Gabarapl1 mRNA levels were found to be significantly lower in tumours presenting a high histological grade, with a lymph node-positive (pN+) and oestrogen and/or progesterone receptor-negative status. In univariate analysis, high gabarapl1 levels were associated with a lower risk of metastasis in all patients (hazard ratio (HR) 4.96), as well as in pN+ patients (HR 14.96). In multivariate analysis, gabarapl1 expression remained significant in all patients (HR 3.63), as well as in pN+ patients (HR 5.65). In univariate or multivariate analysis, gabarapl1 expression did not disclose any difference in metastasis risk in lymph node-negative patients. CONCLUSIONS: Our data show for the first time that the level of gabarapl1 mRNA expression in breast tumours is a good indicator of the risk of recurrence, specifically in pN+ patients.

Radiation therapy has a major role in the management of infiltrative breast cancers. However, there is no consensus for the prophylactic treatment of the internal mammary chain (IMC), with strategies that show strong differences according to centers and physicians. Indications for internal mammary chain radiotherapy are debated, since this treatment significantly increases the dose delivered to the heart and leads to potential technical difficulties. Important prospective data recently suggested that internal mammary chain radiotherapy would not be necessary, even in cases of internal or central tumor locations, or in patients with positive axillary lymph nodes. Although these data warrant confirmation by two other prospective trials, there is evidence that the indications for internal mammary chain radiotherapy should be careful and that high quality techniques should be used for decreasing the dose delivered to the heart. This review of literature presents the state of art on the radiotherapy of internal mammary chain, with special focus on the indications, techniques, and potential toxicity.

Background and Objectives A cancer network was created by Lyon University and by public and private general hospitals of the Rhone-Alpes region in 1995 to improve the quality of cancer care and prescribing practices. After an assessment of the impact of the implementation of criteria derived from clinical practice guidelines (CPGs) relating to the management of patients with breast cancer, significant changes were observed in the network whereas none were observed in a control region with no network and no criteria for CPG implementation (Ray-Coquard et al , 2002).1 An audit carried out 3 years after this first assessment revealed that compliance with CPG criteria had been maintained within the network (Ray-Coquard et al , 2005).2 However, a retrospective study (2001) in the same region gave very different results for the management of rare cancers such as sarcomas (Ray-Coquard et al , 2004).3 Our objective was to perform a prospective evaluation of the management of patients with sarcomas and compare compliance with CPGs in 2005 to that recorded in 2001 and to that obtained for breast cancer. Programme We evaluated prospectively medical practices in the management of patients with sarcomas over a 1-year period (2005). A meeting on the findings of the 2001 retrospective study was held in 2002. Its purpose was to act as a reminder on guidelines for the management of patients with sarcoma. Three years later, all the sarcoma cases included in the study, from the first symptom to relapse or death, had been evaluated. Results 691 cases of suspected sarcoma were reported by the pathologists and 439 were included in our evaluation. Exclusions were due to an incorrect diagnosis, elapsed inclusion date, and relapses. The absence of guidelines for certain subtypes of sarcoma (e.g. Kaposi) meant that 410 cases could be included in the final analysis. Overall compliance was 36% (148/410) in 2005 compared to 32% in 2001. The breakdown of compliance (2005 vs 2001) was as follows: 86% vs 75% for pretherapy, 95% vs 85% for histology, 71% vs 48% for surgery, 86% vs 94% for chemotherapy, 97% vs 90% for radiotherapy and 93% vs 79% for follow-up. Compliance rate remained stable between 2001 and 2005. It was not as good as for breast cancer. Discussion and Conclusion The use of criteria derived from CPGs led to sustained changes in medical practice in our cancer network for the management of breast cancer. Compliance with criteria was a result of intensive implementation and clinician involvement in the drafting of the criteria. However, compliance with CPGs did not increase in the case of the management of sarcomas. It would seem that implementation of CPGs and information meetings are less effective in improving care of patients with rare rather than frequent tumours. Contexte et objectifs En 1995, l9universite et des centres hospitaliers publiques ou prives d9une region francaise ont cree un reseau de cancerologie afin d9ameliorer la qualite des soins et de rationnaliser les prescriptions medicales dans la prise en charge des soins en cancerologie. Dans un premier temps nous avons evalue l9impact de la mise en place d9un referentiel sur les pratiques cliniques dans la prise en charge des patientes atteintes de cancer du sein. Des changements significatifs ont ete observes au sein du reseau alors qu9aucun changement n9etait observe dans une region controle sans reseau de cancerologie et sans implementation de referentiels cliniques (Ray-Coquard 2002). Dans un deuxieme temps et 3 ans apres la premiere evaluation,nous avons evalue la persistance dans le temps des conformites aux referentiels au travers d9un nouvel audit medical. Nous avons eu la confirmation dans cette etude qu9un reseau de cancerologie est a meme de maintenir les pratiques medicales conformes aux referentiels (Ray-Coquard 2005). Au vu des resultats tres differents dans une etude retrospective sur la prise en charge de cancers rares comme les sarcomes dans la meme region (Ray-Coquard 2004), nous avons decide d9evaluer pendant 1 an les pratiques medicales dans la prise en charge des sarcomes au sein d9une cohorte prospective et exhaustive de patients concernes par cette pathologie. Et nous les avons compare aux referentiels nationaux. Suite a l9etude menee en 2001, une reunion a ete organisee en 2002 reporter les resultats de l9etude retrospective et rappeler les regles de prise en charge pour ces tumeurs. Ainsi, 3 ans plus tard tous les sarcomes inclus dans cette nouvelle etude evaluant la prise en charge des patients depuis les premiers symptomes a la rechute ou le deces ont ete evalues. Patients et methodes 691 patients presentant une lesion suspecte de sarcome ont ete declares par les anatomopathologistes: 439 ont vraiment ete inclus (le differentiel est du au mauvais diagnostic, date d9inclusion hors delai et patients declares en rechute). En raison de l9absence de recommandations pour certains sous-types (Kaposi, etc…) 410 ont finalement ete inclus dans l9etude. Nous avons lance une etude prospective et exhaustive (afin d9avoir un effectif representatif) dans la region Rhone-Alpes en 2005 pour evaluer la prise en charge des patients atteints de sarcome afin d9evaluer les pratiques medicales dans cette pathologie. Le taux de compliance aux referentiels a ete compare a la premiere evaluation realisee en 2001 ainsi qu9aux resultats obtenus pour le cancer du sein. Resultats Le taux de conformite globale en 2005 etait de 148/410 (36%) contres 32% en 2001. Le taux de compliance etait donc stable entre 2001 et 2005 et ne semble pas aussi interessant que celui du cancer du sein. Conclusion Le programme des referentiels pour la prise en charge des cancers entraine des changements persistants dans les pratiques medicales dans le temps dans notre reseau de cancerologie en terme de conformite aux referentiels pour le cancer du sein. Les referentiels ont ete suivis lorsqu9ils ont une implementation intensivea ete realisee et que les cliniciens ont participe a leur ecriture. En ce qui concerne les sarcomes, l9implementation de referentiel n9a pas augmente le taux de conformite. Pour les cancers rares l9implementation de referentiels et les reunions informatives ne semblent pas plus efficaces pour ameliorer les pratiques medicales contrairement aux tumeurs frequentes.

Desmoplastic small round-cell tumors in young adults were first described in 1989. They may be revealed by an abdominal mass or a peritoneal carcinomatosis. The diagnosis and the initial treatment are based on debulking surgery. Chemotherapy using doxorubicin, ifosfamide, etoposide and cisplatin can then be proposed. Despite some initial chemosensitivity, prognosis remains poor.

Radiation therapy plays an essential role in the treatment of invasive breast cancer. However, prophylactic treatment of supra- and infraclavicular lymph nodes is not consensual, with different treatment depending on the centres and practitioners. Clinical indications for radiotherapy of the supra- and infraclavicular lymph nodes are often the subject of a consensus. Nevertheless, radiotherapy induces some toxicity. Various techniques have been developed. To date, conformal radiotherapy allows an accurate assessment of doses to target volumes and organs at risk, but at the cost of a sometime complex delineation. This article reviews the literature on radiation of supra- and infraclavicular lymph nodes, with a special focus on technical aspects in delineation and its potential toxicity.

4089 Background: Both the FFCD 9203 [J Clin Oncol 2006;24:4620–5] and the EORTC 22921 [NEJM 2006;355:1114–23] trials showed superiority of neoadjuvant chemoradiation (CT-RT) to radiotherapy (RT) al...

6102 Background: Since 1994, the cancer center of Rhone-Alpes has set up a regional cancer network aiming at improving quality of care through implementation of Clinical Practice Guidelines (CPGs)....

Intra operative radiation therapy is a new look at an old idea (Rich). In relation with the first experience at the Croix-Rousse Hospital with orthovoltage, a review of technical choices, surgical problems, and biological questions is presented. The analysis of literature about accumulated clinical results suggest that local control in recurrence, residual, or inoperable tumor can be obtained by combined surgery IOR, and external beam irradiation. This short experience demonstrate the feasibility of the treatment as a routine and emphasizes the need for continued study.

Following the experience of the German authors, the treatment of choroidal melanoma with ruthenium 106 disk was introduced in Lyon. Between 1983 and 1988, 127 patients were treated. Results are analysed on a group of 84 patients followed 18 months and more. In 72 cases a reduction of thickness was noted. It was complete in 33 cases. Enucleation was performed in 10 patients due to no response or regrowth. In 3 cases the tumor was sterilized. Five patients died of metastases, and 73 are alive, 3 of them with liver metastases. An afterloading iridium template disk was used in 8 patients. 4 of them with a tumor thickness between 6.5 and 8 mm had a good response. Edema of the fovea was observed in 21% of cases, while cataracts were very unusual with Ru 106. An enucleation was performed in 6 patients because of a complication. A useful vision may be preserved in 60% of cases. The scleral tolerance dose is close to 1,500 Gy. These results are in agreement with those of the literature and are considered to be satisfactory for tumors not exceeding 5 to 6 mm in thickness. If the tumor is located close to the fovea or the papilla, and/or if the thickness is 8 mm or more, proton beam could be a good alternative.

Since 1975, 36 patients with squamous cell carcinoma of the penis have been treated with 192 Iridium at the Centre Léon Bérard: 17 T1 lesions, 18 T2 lesions and one T3 lesion. The tumor was less than 4 cm in diameter in 31 cases. Two patients presented with local recurrences after local excision and/or external beam irradiation with 60 Cobalt. In 32 patients followed for more than one year, the rate of local control was 84% (27/32). Five local failures were controlled by subsequent salvage surgery. The rate of severe complications is 25% (8/32): 2 urethral stenoses, 4 necroses, and 2 severe fibrosis. Conservation of a functional organ was possible in 72% of cases (23/32). Amputation was necessary in the 5 patients with lesions of more than 4 cm, because of local failure or painful complications. Ten patients had palpable inguinal lymph nodes, which were found to be involved in 4 cases. Three were controlled by combined radiotherapy and surgery. Among patients off any lymphadenopathy at the time of diagnosis, only one subsequently developed an inguinal metastasis which was controlled by radiotherapy and surgery. The disease-free survival rate was 81% at 3 years (22/27) and 75% at 5 years (12/16). Only one patient died of carcinoma. Curietherapy with 192 Iridium is very suitable treatment for cancers of the penis less than 4 cm in diameter. In most patients, the quality of life will be better than with primary surgical amputation, because sexual function is preserved.

Between 1976 and 1981, 160 patients with non oat-cell carcinoma of the lung underwent a post-operative irradiation. Most of these patients presented with advanced disease, 103 of them with lymphatic involvement. Adjuvant chemotherapy was performed in 48 cases and did not improve the survival rate. Crude survival is 26% at 5 years. No severe complication was related with irradiation. The rate of local relapse was reduced by the irradiation mainly if the dose was above 45 Gy. With doses between 46 and 60 Gy the 5 year survival rate was 33% (11/34) and the rate of local failure was 18%. It is possible that such an irradiation increases the survival rate. Post-operative irradiation seemed advisable after surgery when there is a risk of local residual disease.

Sixty patients with infiltrating bladder cancer were treated by partial cystectomy and iridium radiotherapy between 1977 and 1982. Actuarial 5-year survival was 90% for pT1, 51% for pT2 and 34% for pT3, bladder treatment being unsuccessful in 6 cases (11%). Long-term functional results were satisfactory. Iridium provides better radioprotection than radium and stricter dosage can be established. This conservative treatment for infiltrating bladder cancer is particularly indicated for pT1 and pT2 tumors, as single lesions and with a largest diameter not exceeding 4 cm. Results are better in cases with tumors of the mobile portion of bladder, the 5-year survival in these selected cases being 85% with a minimum of sequelae. This treatment may be used, generally combined with external radiotherapy, for tumors infiltrating deeply into muscle and more distant tissues.

Background A 32% adhesion to CPGs for sarcoma management was reported in a retrospective study (1). To confirm these results, we prospectively assessed the management of all patients diagnosed with sarcoma in the Rhone-Alpes French region (5.9 millions inhabitants) over 2 years. We report the long term follow-up of these patients and investigated parameters significantly correlated to compliance to CPGs. Methods From March 2005 to February 2007, all patients, over 18 years, diagnosed with localized sarcoma in Rhone-Alpes were included and collected through collaboration with all 143 pathologists of this region. No specific dedicated CPGs, are available for patients with Kaposi sarcoma, chondrosarcoma, Ewing sarcoma/PNET and desmoid fibromatosis; these were therefore excluded. Results 634 patients with localized sarcoma were included (soft tissue sarcoma (STS): n = 472; GIST: n = 129; bone primary site: n = 33) for a total incidence of 6.2 /100000/year. Taking into account all parameters defining management (initial diagnosis until follow up), overall conformity to CPGs was only 40%, ranging from 54% for GIST to 36 % for STS. In univariate analysis, adhesion to CPGs for primary management varied according to primary tumor site and hospital. Localization was found to be specifically correlated to compliance to the CPGs concerning initial diagnosis (56% of patients were conformed for limb vs. 71% for trunk localization; P = Adhesion to CPGs Universitary or cancer hospital Private or general hospital Chi-2 test -Diagnostic procedures 83.5% 54.2% -Surgery 81.2% 54.7% -Follow up 94.5% 76.1% Conclusions Conformity to CPGs for initial management of sarcoma was observed in 40% of patients only. Adhesion to CPGs is significantly superior in sarcoma-dedicated cancer center. (1) Ray coquard et al, Ann Oncol. 2004;15:307-15 Disclosure All authors have declared no conflicts of interest.