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We present an update of the French society of oncological radiotherapy recommendation regarding indication, doses, and technique of radiotherapy for intrathoracic metastases. The recommendations for delineation of the target volumes and critical organs are detailed.

We present the update of the recommendations of the French society of oncological radiotherapy on bone metastases. This is a common treatment in the management of patients with cancer. It is a relatively simple treatment with proven efficacy in reducing pain or managing spinal cord compression. More complex treatments by stereotaxis can be proposed for oligometastatic patients or in case of reirradiation. In this context, increased vigilance should be given to the risks to the spinal cord.

In 2021, the Ethics Commission of the SFRO has chosen the issue of the practice of palliative care in radiotherapy oncology. Radiation oncology plays a central role in the care of patients with cancer in palliative phase. But behind the broad name of palliative radiotherapy, we actually find a large variety of situations involving diverse ethical issues. Radiation oncologists have the delicate task to take into account multiple factors throughout a complex decision-making process. While the question of the therapeutic indication and the technical choice allowing it to be implemented remains central, reflection cannot be limited to these decision-making and technical aspects alone. It is also a question of being able to create the conditions for a singularity focused care and to build an authentic care relationship, beyond technicity. It is through this daily ethical work, in close collaboration with patients, and under essential conditions of multidisciplinarity and multiprofessionalism, that our fundamental role as caregiver can be deployed.

Molecular factors influence relapse patterns in glioblastoma. The hotspot mutation located at position 289 of the extracellular domain of the epidermal growth factor receptor (EGFRAn ancillary study from a prospective cohort of patients suffering from glioblastoma was conducted. All patients received radiotherapy and concomitant temozolomide. The population was divided into two groups according to EGFROne hundred twenty-eight patients were included and analyzed: 11% had EGFRWe highlighted a link between the EGFR

Despite significant therapeutic advances in the treatment of locally advanced inoperable non-small cell lung cancer (NSCLC), notably through adjuvant immunotherapy, the rate of therapeutic failure remains high. The use of positron emission tomography with fluorodeoxyglucose (FDG-PET), respiratory motion and intensity modulated radiotherapy (IMRT) have led to therapeutic improvements with reduced toxicity and better local control. The optimal dose to be delivered remains unknown due to discordant results of studies for almost 20 years and the way to define the area to benefit from a dose increase (whole volume, subvolume defined by pre- or per-radiotherapy PET).

Understood as a disruption of the conditions of care practice according to established protocols or procedures, crisis situations in radiation oncology departments can have multiple causes. Their seriousness can sometimes impose changes in the decision-making, organizational or technical paradigms. A possible consequence may be the need to make prioritization decisions in access to care, when there is a mismatch between the care needs of a population and the available health resources (whether technical or human). The specificities of care pathways and the wide variety of clinical situations in radiation oncology make these ethical decisions particularly difficult. Anticipation, collegial and multi-professional decision-making procedures or the integration of patient representatives in these prioritization processes are essential tools. Particular attention must be paid to the information to be provided to patients in a concern of transparency and respect. Prioritization situations are real tests for our departments. They go beyond the purely technical aspect of radiation oncology. They can lead to real ethical suffering for health professionals when their values come up against the limits imposed by crisis situations.

Stereotactic radiotherapy is an ever more common technique, regardless of the location treated. However, spinal stereotactic radiotherapy requires a particular technicality in order to ensure its proper realization. There is now a large literature defining the type of imaging to be used, the dose to be delivered and the delineation of target volumes. This technique can achieve a significant local control and an interesting analgesic efficiency. However, its place in relation to conventional radiotherapy remains limited because it requires MRI imaging and a significantly longer patient management during the treatment fraction. In this context, it is currently mainly restricted to oligometastatic patients or for re-irradiations.

Stereotaxic radiotherapy is performed regularly for the irradiation of non-spine bone metastases, but its place is not well understood.This article in stereotaxic radiotherapy of non-spine bones oligometastases presents the current scientific data relating to the indications, to virtual simulation, to the delineation of target volumes, to the total dose and fractionation, to the efficacy and tolerance.Oligometastatic patients are classified into 4 categories: oligorecurrences, oligometastasis, oligopersistence, oligoprogression. The prognosis will be evaluated according to the following characteristics: primary tumor, quantitative characteristics, kinetics, qualitative characteristics. The delineation of GTV includes extensions to the soft tissue and bone marrow with the aid of MRI and PET. The CTV corresponds to a margin of 2 to 5mm and the PTV to a margin of 2mm. The most widely used irradiation schemes are: 1 single fraction of 18 to 24Gy/1 fr; 24Gy/2 fr; 27 to 30Gy/3 fr; 30 to 35Gy/5 fr. Stereotaxis provides 90% local control at 1 year and good pain control. The side effects are not very marked.Stereotaxic radiotherapy is feasible, non-invasive, minimally toxic and effective with good local control and good pain relief. The main issue remains selecting the patients most likely to benefit from it.

In 2021, the Ethics Commission of the SFRO has chosen the issue of the practice of palliative care in radiotherapy oncology. Radiation oncology plays a central role in the care of patients with cancer in palliative phase. But behind the broad name of palliative radiotherapy, we actually find a large variety of situations involving diverse ethical issues. Radiation oncologists have the delicate task to take into account multiple factors throughout a complex decision-making process. While the question of the therapeutic indication and the technical choice allowing it to be implemented remains central, reflection cannot be limited to these decision-making and technical aspects alone. It is also a question of being able to create the conditions for a singularity focused care and to build an authentic care relationship, beyond technicity. It is through this daily ethical work, in close collaboration with patients, and under essential conditions of multidisciplinarity and multiprofessionalism, that our fundamental role as caregiver can be deployed.

Resume En 2019, le bureau de la Societe francaise de radiotherapie oncologique (SFRO) a cree une commission ethique. Sa mission est de proposer a notre communaute professionnelle des elements de reflexion a propos de questionnements ethiques, et d’en degager les specificites au sein des services d’oncologie radiotherapie. A l’occasion du congres annuel de 2020, la commission s’est penchee sur l’evolution de la relation soigne-soignant, et plus particulierement sur l’idee forte de partenariat patient. En effet, la redaction du Livre blanc du cancer a donne la parole aux personnes malades et souligne la necessite de nouveaux dispositifs, tels que le « temps d’accompagnement soignant ». Les patients ne peuvent plus etre consideres comme des objets de soin mais comme des personnes dont la dignite et l’autonomie doivent etre imperativement respectees. L’acquisition de connaissances autorise un echange bilateral, prerequis de la dynamique collaborative. Ils peuvent etre partenaires de leurs propres soins, partenaires de la formation et de la recherche (patient expert) mais egalement partenaires des institutions et politiques de sante. C’est cette notion de partenariat et d’implication de la personne dans son parcours de soin en oncologie radiotherapie que nous allons analyser ici. Il s’agira autant de la definir, en developpant la notion d’autonomie, que d’en faire emerger la complexite et l’ambivalence au travers notamment de deux exemples issus de notre pratique clinique : la demarche de decision partagee pour les patients ayant un cancer de la prostate localise et l’implication du patient dans le bon deroulement de sa radiotherapie.

Immediate breast reconstruction versus delayed breast reconstruction improves quality of life of breast cancer patients undergoing total mastectomy without impacting oncologic outcomes. Two types of immediate reconstruction are possible, implant-based reconstruction or autologous reconstruction. These reconstructions interpose a tissue in the operating bed, which modifies target volume definition compared to a wall without reconstruction Post mastectomy radiotherapy increases the rate of postoperative complications for both surgical procedures. Recent guidelines were published about target volume definition in the post mastectomy setting after implant-based reconstruction. Guidelines about target volume definition after autologous reconstruction are still awaited. The aim of our work is to present the different surgical procedures for immediate breast reconstruction, their complications, and the definition of the postmastectomy target volume.

Multimodal imaging has become a standard for planning radiation therapy via magnetic resonance imaging (MRI) or positron emission tomography (PET) in many cancers. However, its use is now old, and its impact has not been much discussed in light of technological improvements in imaging and advances in radiotherapy. However, in 20 years, the exclusive functional imaging has been replaced by hybrid imaging (functional and anatomical) with successive improvements (flight time, detector modifications, digitisation, etc.) have enabled us to go from centimetric resolution to the current 3 to 4mm resolution. This article will specifically review PET technology, its latest advances and the potential impact on radiotherapy, particularly head and neck cancers.

In 2019, the scientific committee of the French society of radiation oncology (SFRO) created an ethics committee. Its mission is to provide our professional community with food for thought on ethical issues, and to identify its specificities within the radiation oncology departments. For the 2020 annual conference, the commission looked into the evolution of the patient-carer relationship, and more particularly to the strong idea of patient partnership. Indeed, the writing of the White Book of Cancer gave voice to sick people and stressed the need for new devices, such as the Caregiving Time. Patients can no longer be considered as objects of care but as people whose dignity and autonomy must be imperatively respected. The acquisition of knowledge allows a bilateral exchange, prerequisite of a dynamic collaboration. Patients can be partners in their own care, partners in training and research (expert patient), but also partners in health institutions and policies. It is this notion of partnership and involvement of the person in their path of care in radiation oncology that we will analyse here. It will be about defining it, by developing the concept of autonomy, and bringing out its complexity and ambivalence through two examples from our clinical practice: the shared decision-making process for patients with localized prostate cancer and the patient's involvement in the success of his radiotherapy.

Resume But de l’etude Nous avons analyse les caracteristiques et le retentissement des violences numeriques effectuees chez des victimes, en grande majorite adultes, venus consulter dans une unite medico-judiciaire. Jusqu’a present, les etudes ayant trait a ce type de violences ont ete rares chez l’adulte, et effectuees dans le monde du travail. Patients et methodes Pendant deux annees consecutives, des informations ont ete colligees concernant la duree des violences numeriques, leur type, la presence de violences verbales en face a face ou de violences physiques associees, ainsi que le retentissement psychologique chez les victimes. Une comparaison a ete effectuee entre les deux annees. Resultats Les victimes ont ete le plus souvent des femmes, la majorite des violences numeriques etant pratiquee par le conjoint ou l’ex-conjoint (82 %). Les violences numeriques ont ete repetees dans 82 % des cas, et l’intervalle de temps durant lequel elles sont survenues a ete respectivement inferieur a 8 jours et superieur a 1 an chez 29 % et 25 % des victimes. Des violences verbales en face a face ont ete associees dans 70 % des cas, et des violences physiques dans 82 % des cas. Le retentissement psychologique, present chez 69 % des consultants, a ete plus frequent lorsque des violences physiques etaient associees (p = 0,0009), sans difference entre les deux annees consecutives. Conclusion En cas de violences conjugales, il est donc important, lors des consultations, de rechercher systematiquement des episodes de violences numeriques, en particulier du fait de la frequence elevee du retentissement psychologique observe chez les victimes.

Introduction En France, 10-11 % des patients avec un cancer broncho-pulmonaire non a petites cellules (CBNPC) sont diagnostiques avec une mutation EGFR (EGFRm + ). Les traitements standards de premiere ligne des CBNPC EGFRm+ sont des inhibiteurs de tyrosine kinase (TKI). L’objectif de cette etude etait de decrire la prise en charge en vie reelle des patients CBNPC EGFRm+. Methodes Le programme Epidemio-Strategie Medico-Economique (ESME) de Unicancer est une cohorte retrospective nationale qui recueille des donnees sur le diagnostic, la prise en charge therapeutique et le suivi de patients (pts) traites pour un CBP parmi 33 etablissements de sante. Les principaux criteres d’inclusion de cette analyse sont: ≥ 18 ans, confirmation histologique du CBNPC, diagnostic de maladie avancee ou metastatique entre le 1er janvier 2015 et 31 decembre 2016, EGFRm+, sans traitement systemique prealable. Cut-off: 15 mars 2019. Resultats La recherche de mutation EGFR etait effectuee chez 54 % des 13537 pts CBNPC inclus dans la base et 56 % des cas non-epidermoides localement avance ou metastatique. Parmi les testes, 1171 pts (16 %) etait EGFRm+. 560 pts repondaient aux criteres d’inclusion. Cette population etait composee a 65 % de femmes, âge median 66 ans, 99 % d’histologie non-epidermoide, 85 % Stade IV de novo. Parmi eux 65 % etaient identifies EGFRm+ avant initiation d’une premiere ligne de traitement (42 % Exon19Del, 33 % L858R, 2 % T790 M, 11 % autre mutation, [categories non-exclusives]). Un traitement de premiere ligne a ete administre a 534 pts (95.4 %). La majorite a recu en premiere ligne un traitement par un EGFR-TKI en mono-therapie: 46 % gefitinib ou erlotinib, 15 % afatinib; 18 % un traitement par chimiotherapie (CT), principalement a base de sel de platine. 355 pts (77.0 %) ont recu une deuxieme ligne de traitement, dont 29 % CT, 29 % osimertinib et 23 % un autre EGFR-TKI. Parmi les CBNPC EGFRm+ avec T790 M (138 pts), 87 (63 %) ont recu osimertinib en deuxieme ligne. Apres un suivi median de 31.8 mois (95 %CI: 29.0; 33.6), 266 patients sont decedes. La mediane de survie globale est de 30.1 mois (95 %CI: 28.3; 33.7). Conclusion Pour la periode de selection, seule la moitie des patients CBNPC non-epidermoides ont fait l’objet d’une recherche de mutation EGFR. L’efficacite des EGFR TKIs apparait similaire en vie reelle a celle rapportee dans les essais cliniques. Les Resultats suggerent que plus de patients pourraient beneficier de cette recherche et d’un TKI en premiere ligne conformement aux recommandations.

Resume Introduction La mort inattendue du nourrisson touche environ 500 enfants chaque annee en France. Malgre des recommandations, leur prise en charge initiale est parfois problematique. L’objectif de ce travail etait de faire un etat des lieux du parcours de ces nourrissons, d’identifier les difficultes rencontrees et de proposer des recommandations simples. Materiels et methode Nous avons realise une etude observationnelle, monocentrique, retrospective, portant sur les dossiers des nourrissons admis au centre hospitalier universitaire de Rouen suite a une mort inattendue. Les donnees relatives a leur prise en charge pre-hospitaliere et hospitaliere initiale, tant au centre de reference de la mort inattendue du nourrisson qu’a l’institut medicolegal, ont ete recueillies. Un protocole a ensuite ete etabli lors d’une reflexion pluridisciplinaire. Resultats Cinquante et un dossiers de nourrissons pris en charge entre le 1 er janvier 2011 et le 31 decembre 2015 ont ete analyses. Le service d’aide medicale d’urgence est intervenu dans 67 % des cas. Un obstacle medicolegal a ete pose pour 27 % des enfants. Au total, 41 % et 59 % des enfants ont beneficie respectivement d’une prise en charge medicolegale et scientifique. Parmi les 14 % d’enfants reorientes vers la filiere medicolegale, un seul dossier a pose d’importantes difficultes. Suite a cette situation, un logigramme des differents parcours possibles a ete cree au cours de reunions de travail pluridisciplinaires mensuelles, sur une duree de 7 mois. Conclusion Des progres sont encore a faire afin de clarifier et fluidifier la prise en charge des nourrissons victimes de mort inattendue et de leur famille. Un decloisonnement et une collaboration pluridisciplinaire etroite sont indispensables, de meme que la creation de guidelines semble essentielle pour simplifier cette prise en charge peu commune.

International audience; La prescription de la dose en radiothérapie est actuellement basée sur des abaques qui ne prennent pas en compte la complexité de la relation patient/dose/effet. Leurs performances prédictives tant sur l’efficacité anti-tumorale que sur la toxicité peuvent être améliorées par l’utilisation de modèles radiobiologiques. C’est dans cette optique qu’ont été développés les modèles de calculs TCP (Tumor Control Probability) et NTCP (Normal Tissue Complication Probability). Leur construction comporte plusieurs étapes importantes utiles à comprendre. La première étape est basée sur les modèles radiobiologiques permettant de définir de manière plus ou moins complexe des taux de cellules survivantes après irradiation. Deux étapes supplémentaires sont nécessaires pour convertir la dose physique en dose biologique équivalente, notamment en dose biologique équivalente à 2 Gy (EQD2) ; d’une part, pour prendre en compte l’effet du fractionnement de la dose, tant pour le volume cible que les organes à risque, et d’autre part, pour réaliser sa conversion en une dose uniforme qui permet de modéliser l’effet produit par une dose hétérogène sur un organe (dose uniforme équivalente généralisée (gEUD) de Niemierko). Enfin, les modèles radiobiologiques de prédiction des effets cliniques transforment les doses en probabilités de contrôle tumoral (TCP) ou de toxicité (NTCP) en recourant aux paramètres qui rendent compte des caractéristiques radiobiologiques des tissus en question. L’utilisation de ces modèles est encore limitée en pratique courante mais comme les logiciels de radiothérapie en propose l’utilisation, il est important d’en connaître les conditions d’application.

In radiotherapy, the dose prescription is currently based on discretized dose-effects records that do not take into fully account for the complexity of the patient-dose-response relationship. Their predictive performance on both anti-tumour efficacy and toxicity can be optimized by integrating radiobiological models. It is with this in mind that the calculation models TCP (Tumor Control Probability) and NTCP (Normal Tissue Complication Probability) have been developed. Their construction involves several important steps that are necessary and important to understand. The first step is based on radiobiological models allowing to calculate according to more or less complexity the rate of surviving cells after irradiation. Two additional steps are required to convert the physical dose into an equivalent biological dose, in particular a 2Gy equivalent biological dose (EQD2): first to take into account the effect of the fractionation of the dose for both the target volume and the organs at risk; second to convert an heterogeneous dose to an organ into an homogeneous dose having the same effect (Niemierko generalized equivalent uniform dose (gEUD)). Finally, the process of predicting clinical effects based on radiobiological models transform doses into tumour control (TCP) or toxicity (NTCP) probabilities using parameters that reflect the radiobiological characteristics of the tissues in question. The use of these models in current practice is still limited, but since the radiotherapy softwares increasingly integrate them, it is important to know the principle and limits of application of these models.

PET/CT has become a standard examination in oncology but is probably still underused for radiotherapy planning. However, except for the clinical research data that shows the interest of this examination in considering personalized and adaptive radiotherapy, it is also important in defining target volumes. However, before using it in clinical practice, a few prerequisites are required to know the acquisition and segmentation methods. Ideally, PET/CT should become a standard examination for radiotherapy departments in the same way as planning CT and tomorrow as MRI.

Adjuvant radiotherapy is a key treatment in early-stage breast cancer. The meta-analysis by the Early Breast Cancer Trialist's Collaborative Group (EBCTCG) has demonstrated a decreased risk of locoregional relapse and death after whole-breast radiotherapy. Prophylactic lymph nodes irradiation in breast cancer has also proven to be beneficial in several therapeutic trials. At a time when three-dimensional conformal radiotherapy has become the standard procedure and with the development of intensity-modulated radiation therapy, defining nodal volumes is essential and practices should be harmonized to assess and compare the efficiency and toxicity of radiotherapy. Furthermore, the indication of lymph nodes irradiation has to take into account the risk/benefit balance as expanding the irradiated volume can increase radio-induced toxicity. Selection of patients receiving this treatment is essential. The aim of this update is to define nodal volumes, to precise the indications of their irradiation and to present the expected benefits as well as the potential side effects.

Due to high dose gradients, stereotactic body radiation therapy requires high precision in the location of the tumour. Uncertainties in the positioning can introduce serious damage on organs at risk and consequently can reduce tumour local control. A better tumour location can be achieved by controlling its position with an efficient inter and intrafraction imaging procedure. The various imaging techniques available on treatment systems are presented and performances are discussed. Finally, propositions are given in terms of imaging system according to the location treated by stereotactic body radiation therapy.

Introduction La tomographie par emission de positons couplee au scanner (TEP-TDM) est realisee pour tous les patients avec une tumeur pulmonaire presumee operable. Certains patients ont une hyperfixation au niveau des muscles respiratoires dont la signification n’est pas determinee. Cet hypermetabolisme des muscles respiratoires (HMR) pourrait traduire une fragilite respiratoire et etre associe a des complications postoperatoires. Notre objectif etait d’evaluer la valeur predictive de l’HMR pour le diagnostic des complications postoperatoires chez les patients operes d’un cancer bronchique (CB). Nos objectifs secondaires etaient d’evaluer les caracteristiques cliniques et physiologiques associees a l’HMR. Methodes Etude retrospective incluant tous les patients operes d’un CB entre 2013 et 2018 avec TEP-TDM et EFR preoperatoires. L’HMR etait defini comme une valeur d’absorption maximale (SUVm) > 90e percentile sur un des groupes musculaires [sternocleidomastoidiens (SCM), scalenes (Sc), intercostaux (IC), diaphragme (D)] apres correction par la SUVm du deltoide. Les complications etaient colligees a partir de la base de donnees prospective EPITHOR. Resultats Cent cinquante-huit patients ont ete inclus, dont 112 (71%) hommes, avec un tabagisme a 39,2 ± 22,8 paquets-annees. L’index de Charlson etait de 5 (4–6) et le score ASA de 2 (2–3). Soixante-cinq (41,1%) avaient une BPCO, 17 (10,8%) une apnee du sommeil. Les resections etaient : n = 120 (76%), n = 13 (8,2%) pneumonectomies, n = 12 (7,6%) segmentectomies et n = 13 (8,2%) resections atypiques. L’abord etait majoritairement mini-invasif [117 (74,1%)]. Cinquante-trois patients (33,5%) ont eu des complications respiratoires. Les SUVm corriges des MR etaient de : SCM 1,80 ± 0,87 ; Sc 1,98 ± 0,67 ; IC 1,02 ± 0,25 ; D 1,88 ± 0,63. L’HMR [n = 47 (29,7%)] n’etait pas predictif de la survenue de complications respiratoires (OR 1,03 [0,50–2,11]) mais etait plus souvent retrouve chez des patients BPCO (OR 3,36 [1,67–6,69], p Conclusion L’HMR n’etait pas predictif de la survenue de complications respiratoires dans notre cohorte. Les SUVm des MR etaient correles a la fonction respiratoire illustrant un lien pathophysiologique entre fonction ventilatoire et metabolisme musculaire respiratoire.

Introduction Le programme Epidemio-Strategie Medico-Economique (ESME) de Unicancer est une cohorte retrospective nationale qui recueille des donnees sur le diagnostic, la prise en charge therapeutique et le suivi de patients (pts) traites pour un cancer bronchopulmonaire (CBP) dans 33 etablissements de sante. L’objectif de cette analyse est de decrire les modalites de prise en charge des cancers bronchiques a petites cellules (CBPC) metastatiques en vie reelle. Methodes Les criteres d’inclusions etaient : âge > 18 ans, confirmation histologique du CBPC, diagnostic de maladie metastatique (de novo ou rechute), recevant une premiere cure par etoposide + chimiotherapie a base de sel de platine (PT) a partir du 1er janvier 2015. Resultats Parmi 2374 pts CBPC dans la base de donnees ESME CBP, 1315 pts (55%) repondaient aux criteres d’inclusions : hommes : 64%, âge median : 64 ans, ECOG 0-1 : 57% (quand disponible) et fumeurs ou ex-fumeurs : 92%, stade IV de novo : 90%. 24% des pts avaient ≥ 3 sites metastatiques au diagnostic. Les sites metastatiques les plus frequents etaient hepatiques (43%), osseux (36%), cerebraux (32%), et surrenaliens (24%). Parmi les pts avec metastases cerebrales, 35% etaient symptomatiques au diagnostic. 49% des patients ont recu une seule ligne de traitement, tandis que 30% ont recu deux lignes et 21% ≥ 3 lignes. En premiere ligne, la majorite des patients ont recu etoposide + PT seuls (67% etoposide + carboplatine ; 20% etoposide + cisplatine) avec une duree mediane de traitement similaire : 3.6 mois (IC95% : 2,5–4,0) avec etoposide + carboplatine, 3,6 mois (IC95% : 2,3–4,0) etoposide + cisplatine. Apres un suivi median de 20,1 mois (IC95% : 19,0–22,0) dans la population d’interet, 1052 pts (80,0%) ont progresse ou sont decedes. La mediane de survie sans progression (SSP) selon l’investigateur etait de 5,8 mois (IC95% : 5,4–6,0) et 6,1 mois (IC95% : 5,6–6,7) respectivement. La mediane de survie globale etait de 11,0 mois (IC95% : 10,4–11,8) avec etoposide + carboplatine et 14,2 mois (IC95% : 13,1–16,5) avec etoposide + cisplatine (HR = 1,302, IC95% : 1,196–1,621, p Conclusion Les resultats montrent que la plupart des patients avec CBPC de stade IV recoit un traitement par etoposide + sel de platine avec une proportion beaucoup plus importante de patients traites par carboplatine que cisplatine. Les resultats obtenus avec ces traitements en termes de duree de traitement, de survie sans progression, et survie globale sont similaires a ceux reportes dans les essais cliniques.

Since decades, stereotactic radiotherapy has spread out worldwide. Published results are very numerous. To clarify obviousness among all the publications, this recommendation review was written. Voluntarily, authors limited analysis of international best evidence literature on malignant tumors of lung, liver, prostate, head and neck, and metastasis of bone and brain. These data could be used to advance standardization and quality improvement of treatments performed in the nationwide radiotherapy departments and can provide useful guidance for centers worldwide.

Image-guided radiotherapy takes place at every step of the treatment in lung cancer, from treatment planning, with fusion imaging, to daily in-room repositioning. Managing tumoral and surrounding thoracic structures motion has been allowed since the routine use of 4D computed tomography (4DCT). The integration of respiratory motion has been made with "passive" techniques based on reconstruction images from 4DCT planning, or "active" techniques adapted to the patient's breathing. Daily repositioning is based on regular images, weekly or daily, low (kV) or high (MV) energy. MRI and functional imaging also play an important part in lung cancer radiation and open the way for adaptative radiotherapy.

Introduction La radiochimiotherapie est le traitement de reference du cancer broncho-pulmonaire non a petites cellules localement avance non resecable, avec neanmoins des Resultats en termes de survie insatisfaisants, en partie dus a une resistance aux radiations des tissus hypoxiques. Nous avons emis l’hypothese qu’une augmentation de dose (boost) pouvait lever cette resistance. Une premiere etape fut donc de realiser une etude pilote pour evaluer la possibilite de detecter des tumeurs hypoxiques au 18F–MISO puis de leur administrer un boost de radiotherapie sans induire de toxicite inacceptable. Methodes L’essai clinique RTEP5 (Clinicaltrial NCT01576796 ) ouvert, non randomise, multicentrique, a ete realise entre 2012 et 2018, incluant un suivi a trois ans dans 15 centres en France. La tumeur a ete diagnostiquee hypoxique lorsqu’une fixation au Fluoromisonidazole (18F–MISO) etait revelee a la tomographie par emission de positrons (TEP)/tomodensitometrie (TDM). Celles (dites 18F–MISO positives) non proches d’un organe a risque ont recu un boost de radiotherapie (70–86 Gy) ; les autres ont ete traitees par le schema standard (66 Gy). Nous avons realise une analyse par score de propension pour evaluer l’efficacite du boost, en termes de survies globale (SG) et sans progression (SSP), dans cette etude pilote pour laquelle une randomisation n’a pas ete planifiee. Resultats Soixante-dix-neuf patients ont ete preselectionnes et 54 inclus, dont 34 ayant une tumeur 18F-MISO positive parmi lesquels 24 ont recu un boost de radiotherapie allant jusqu’a 86 Gy. Les taux de SG et SSP a 1, 2 et 3 ans etaient, respectivement, de 87 %, 58,2 %, et 48,5 %, avec un temps de survie median de 27,7 mois. Concernant la SSP, les taux a 1, 2 et 3 ans etaient de 59,3 %, 36,4 %, et 28,8 %, avec un temps de survie median de 14,5 mois. Les tumeurs hypoxiques etaient de diametre significativement plus grand que celles non hypoxiques (57,6 versus 29,8 mm, p Conclusion Dans un contexte d’etude pilote ou plusieurs questions sont posees, il n’est pas toujours simple de prevoir une methodologie permettant d’y repondre selon une puissance statistique forte et sans biais. Cette etude montre la possibilite d’administrer un boost de radiotherapie a des tumeurs hypoxiques sans compromettre la securite du patient. Le score de propension nous a permis de pallier aux desequilibres dans les caracteristiques des echantillons afin d’apporter un premier element de reponse encourageant mais non decisionnel sur l’efficacite du boost. Cette efficacite est a confirmer dans le cadre d’une etude randomisee a plus large echelle.

La radiotherapie antalgique des metastases osseuses de premiere intention est un traitement efficace quel que soit le fractionnement (traitement mono- ou plurifractionne). La radiotherapie peut egalement etre proposee en cas d’echec ou d’efficacite insuffisante d’une premiere irradiation (apres avoir elimine une fracture) ou l’apparition de nouveaux sites douloureux. Les autres indications sont les compressions medullaires en adjuvant a la chirurgie ou de facon exclusive et les irradiations apres chirurgie pour metastase des os longs. Le developpement de la radiotherapie de haute precision (en conditions stereotaxiques) augmente les possibilites de reirradiation lorsque les doses maximales admissibles par les tissus sains ont ete atteintes. Elle cherche a ameliorer le controle local, voire la survie, chez les patients oligometastatiques.

Questionnaire of the survey. (DOCX 52Â kb)

Resume Introduction La concordance entre l’autopsie medico-legale (AML) et le scanner post-mortem (SPM) pour detecter les lesions en fonction des differents sites anatomiques a ete etablie, ainsi que la sensibilite du SPM pour montrer les lesions considerees comme letales lors de l’AML. Methodes Les examens realises avec un scanner spirale 64 detecteurs, ont ete lus par un ou par deux radiologues pour les 236 premiers cas, ayant une expertise reconnue en matiere d’imagerie post-mortem. Le test du Kappa de Cohen a ete utilise pour le calcul des concordances. Resultats Alors que 506 SPM ont ete effectues, l’etude n’a concerne que les 336 SPM pour lesquels une reference autopsique etait disponible. La concordance entre le SPM et l’AML a ete excellente pour les lesions fracturaires et mediocre pour les plaies vasculaires ou viscerales. La sensibilite du SPM pour detecter les lesions letales observees lors de l’AML a ete de 100 % apres traumatisme crânien, 91 % en cas de plaie balistique, 50 % en cas de plaie par arme blanche, 59 % apres pendaison et 38 % lorsque la mort etait naturelle. Parmi les lesions osseuses objectivees par le SPM, 26 % n’ont pas ete montrees par l’AML. La concordance entre les deux radiologues a ete excellente (Kappa de Cohen = 0,95). Conclusions Notre etude montre que le scanner post-mortem est capable de detecter des lesions non vues a l’autopsie, en particulier au niveau des structures osseuses, et sa sensibilite est excellente pour detecter les lesions letales en cas de traumatisme craniofacial ou de plaies balistiques.

International audience; After the liver and lungs, bones are the third most common sites of cancer metastasis. Palliative radiotherapy for secondary bone tumours helps relieve pain, improve the quality of life and reduce the risk of fractures. Stereotactic body radiotherapy can deliver high radiation doses with very tight margins, which has significant advantages when treating tumours close to the spinal cord. Strict quality control is essential as dose gradient at the edge of the spinal cord is important. Optimal schedule is not defined. A range of dose-fractionation schedules have been used. Pain relief and local control are seen in over 80%. Toxicity rates are low, although vertebral fracture may occur. Ongoing prospective studies will help clarify its role in the management of oligometastatic patients.

International audience; Technological progress in radiotherapy enables more precision for treatment planning and delivery. The margin determination between the clinical target volume and the planning target volumes stem from the estimation of geometric uncertainties of the tumour localization into the radiation beam. The inner motion complexity of lung tumours has led to the use of 4D computed tomography and nurtures specific dosimetric concerns. Few strategies consisting in integrating tumour motion allow margin reduction regarding inner movements. The patient immobilization and onboard imagery improvement decrease the setup uncertainties. Each step between the initial planning imagery and treatment delivery has to be analysed as systematic or random errors to calculate the optimal planning margin.

Resume La determination des volumes-cibles est la preoccupation majeure des radiotherapeutes. La necessite de delivrer des doses elevees pour esperer un controle local dans les cancers bronchiques non a petites cellules, tout en evitant des lesions graves des organes a risque adjacents (notamment les poumons), rend indispensable une localisation precise de la tumeur primitive et des aires ganglionnaires envahies. L’imagerie par tomodensitometrie est insuffisante pour reduire le volume cible mediastinal. La tomographie par emission de positons (TEP) au 18-fluorodeoxyglucose (FDG) ameliore la qualite du bilan d’extension a distance, aide a la determination du volume-cible (notamment ganglionnaire mediastinal), et fournit des informations sur le pronostic. Malgre des difficultes techniques (resolution des images, superposition d’images multimodalite, criteres de delineation des zones hypermetaboliques), la TEP-FDG est devenue incontournable. Sa place dans l’adaptation des doses d’irradiation doit cependant etre evaluee par des etudes cliniques prospectives de grande echelle.

International audience; Post-mortem CT-scan (PMCT) has become increasingly useful as a diagnostic tool. However, certain normal postmortem changes may mimic the appearance of pathologic findings. We report two cases of false positive aortic dissection.METHODS:Non-contrast PMCT was performed on a sixty-four-detector row scanner. Each PMCT examination was assessed and reported by two independent radiologists. Autopsies were performed according European recommendations.CASES:In two corpses, a false positive DeBakey type I aortic dissection was detected. Autopsies confirmed that CT findings were artifactual. For each case the cause of the mistake was individually discussed and mainly based on the abnormalities observed during the autopsy. In fact, in our series (750 PMCT) a true aortic dissection was detected in two corpses during the same period.CONCLUSION:When a PMCT is performed, false positive aortic dissection can occur, which confirms the interest in combining opacification.

Because few studies demonstrated the types of violence performed by women, the aim of our study was to access violence men against women as well as women against men. A retrospective study was performed based on all the medical certificates for victims who consulted our centre specialized in assault victims. Eleven percent of the victims were men (81 men, 626 women). Episodes of violence were most often repeated against women than men (p < 0.05). Injuring, in most cases mild, were more frequently found in men than women (p < 0.01). They were primarily cutaneous in 66% of cases (85% men, 64% women) and severe in 5% of cases i.e. fractures, with no difference in gender. Three cases of sexual assault and one case of chemical submission was observed in women. Insults were made more often by men than by women (p < 0.002). A psychological impact was more frequently found in women than in men (p < 0.01). The duration of the total incapacity (incapacite totale de travail = ITT) was less than 0-3 days in most cases, and this occurred more often in 91% men than in 65% women (p < 0.01). Consultations for domestic violence occur less frequently in men than in women. Men present more often with injuries that are less severe compared to those observed in women. In contrast, the psychological impact is less frequent in men. Also episodes of violence were most often repeated when the aggressor was a man.

The dense lymphatic network of the esophagus facilitates tumour spreading along the cephalo-caudal axis and to locoregional lymph nodes. A better understanding of microscopic invasion by tumour cells, based on histological analysis of surgical specimens and analysis of recurrence sites, has justified a reduction in radiotherapy target volumes. The delineation of the clinical target volume (CTV) depends on tumour characteristics (site, histology) and on its spread as assessed on endoscopic ultrasonography and ((18)F)-fluorodeoxyglucose positron-emission tomography (FDG-PET). We propose that positive and negative predictive values for FDG-PET should be used to adapt the CTV according to the risk of nodal involvement.

The number of obese patients has increased in France over the last two decades, which has had an impact on the incidence of numerous types of cancer. The treatment of cancer by radiotherapy is impacted by obesity as a result of the physical, technical and dosimetric constraints, the acute and late toxicity, local control and the survival of patients.

Acute radiation-induced esophagitis includes all clinical symptoms (odynophagia, dysphagia) occurring within 90 days after thoracic irradiation start. Its severity can be graded using RTOG and CTCAE scales. The clinical risk factors are: age, female gender, initial performance status, pre-therapeutic body mass index, pre-therapeutic dysphagia, tumoral and nodal stage, delivered dose, accelerated hyperfractionned radiotherapy, concomitant association of chemotherapy to radiotherapy and response to the treatment. The dosimetric parameters predictive of esophagitis are: mean dose, V(20Gy), V(30Gy), V(40Gy), V(45Gy) and V(50Gy). Amifostine is the only drug to have a proven radioprotective efficacy (evidence level C, ESMO recommendation grade III). The medical management of esophagitis associates a diet excluding irritant food, medication against gastroesophageal reflux, analgesic treatment according to the WHO scale and management of dehydration and denutrition by enteral feeding.

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

The objective of this study was to compare prospectively the delineations of tumour bed after breast conserving surgery from two techniques for defining the target volume.Sixteen patients treated by lumpectomy with development of surgical clips were included. For each patient, four radiation oncologists delineated the clinical target volume (CTV boost) following its own method (technique 1) or using a predefined methodology (technique 2), the diameter to be applied around each clip relative to the risk of local recurrence. Factors taken into account to adjust the volume were tumour size, age, surgical margins and the presence of extensive ductal carcinoma. We then analyzed the factors varying the volume and variation of delineation for each method by calculating the concordance index: Kappa index and overlap.For all 16 patients, the volume delineated was nearly identical: 29.65 cm(3) with technique 1 and 33.54 cm(3) with technique 2 (P=0.6). The correlation was higher with technique 2 over technique 1, with KI from 0.146 to 0.285 (P=0.0001) and an OV of 0.302 to 0.458 (P=0.0002).Our study shows that within the same institute, there is a great variability in CTV delineation boost, even in the presence of surgical clips. A standardized approach to adjusting the volume of relapse risk factors has improved the consistency.