Innovations en radiothérapie

Radiotherapy is a major treatment for cancer curability. During recent years, radiotherapy has gained in precision and reproducibility using major technological advances. Three-dimensional conformal radiotherapy has been implemented into routine practice with the delineation of tumor volumes and organs at risk and the use of dosimetry (integrating dose constraints and dose-volume histograms). Intensity-modulated radiation therapy (IMRT) can ??sculpt?? the dose around treatment volumes to spare normal tissues more efficiently. Image-guided radiation therapy is now widely used to control the position of the target during a treatment course. Dynamic arctherapy is a way to optimize IMRT using arctherapy, an old concept that makes IMRT delivery quicker and accessible for a larger patient load. Concepts in radiotherapy are strong and will be deployed on all radiotherapy units. Radiation oncology is probably only at its dawn. These innovations open a promising future for improvements in the cure of cancer.     

Radiothérapie adaptative ORL

Onboard volumetric imaging systems can provide accurate data of the patient's anatomy during a course of head and neck radiotherapy making it possible to assess the actual delivered dose and to evaluate the dosimetric impact of complex daily positioning variations and gradual anatomic changes such as geometric variations of tumors and normal tissues or shrinkage of external contours. Adaptive radiotherapy is defined as the correction of a patient's treatment planning to adapt for individual variations observed during treatment. Strategies are developed to selectively identify patients that require replanning because of an intolerable dosimetric drift. Automated tools are designed to limit time consumption. Deformable image registration algorithms are the cornerstones of these strategies, but a better understanding of their limits of validity is required before adaptive radiotherapy can be safely introduced to daily practice. Moreover, strict evaluation of the clinical benefits is yet to be proven.     

Formation en curiethérapie

Treatment technique training needs theoretical and practical knowledge allowing proposing the right treatment for the right patient, but also allowing performing the technical gesture in the best conditions for an optimal result with a maximal security. The evolution of the brachytherapy techniques needs the set up of specific theoretical and practical training sessions. The present article focuses on the importance of the brachytherapy training as well as the different means currently available for the young radiation oncologist community for perfecting their education. National and international trainings are presented. The role of the simulation principle in the frame of brachytherapy is also discussed. Even if brachytherapy is not always an easy technique, its efficacy and its medico-economical impact need to be passed down to motivated students with the implementation of relevant educational means.     

Sécurité en curiethérapie

No technique can now be used without previously considering the safety of patients, staff and public and risk management. This is the case for brachytherapy. The various aspects of brachytherapy are discussed for both the patient and the staff. For all, the risks must be minimized while achieving a treatment of quality. It is therefore necessary to establish a list as comprehensive as possible regardless of the type of brachytherapy (low, high, pulsed dose-rate). Then, their importance must be assessed with the help of their criticality. Radiation protection of personnel and public must take into account the many existing regulation texts. Four axes have been defined for the risk management for patients: organization, preparation, planning and implementation of treatment. For each axis, a review of risks is presented, as well as administrative, technical and medical dispositions for staff and the public.     

La chimiothérapie et la chimioradiothérapie préopératoires des cancers bronchiques non à petites cellules

The very disappointing results obtained by surgery in resectable non-small-cell lung cancer have led to a high active clinical research concerning pre- or postoperative treatment. Preoperative treatment has several distincts goals: to increase survival for patients suitable for surgery, to limit surgery or transform borderline or non resectable cancer into resectable tumors. Available datas on preoperative treatments for non-small-cell lung cancer provide from three types of therapeutics trials: 1/ Some phase II studies of neoadjuvant chemotherapy have demonstrated that the neoadjuvant approach was feasible, and didn’t compromise surgery. 2/ Phase II trials of neoadjuvant chemoradiotherapy, performed for the majority on more extensive cancers, have demonstrated that this approach was also feasible at the expense of higher but still tolerable toxicity. 3/ Phase III randomised published trials exclusively deal with preoperative chemotherapy with different results: two of them concerned a small number of patients presenting with non-small-cell lung stage IIIA cancer: they are positive. The third concerned 373 patients presenting with stage I, II, IIIA cancer: the three-year survival was increased by 11%, but this difference is not yet significant. The benefit essentially appeared for stage I and II. One trial comparing preoperative chemotherapy and radiochemotherapy has been reported, concluding to the superiority of the association. These observations suggest that the clinical research should now be different for stages I and II, and stage IIIA.     

Curiethérapie du canal anal

Low dose-rate brachytherapy as a boost after concomitant chemoradiation therapy is a standard of care for locally advanced anal carcinoma, providing a rigorous selection taking into account the initial staging and tumor response to external beam radiotherapy. Local control is likely to be superior when the boost is performed with brachytherapy than with external beam radiotherapy. The several steps of the brachytherapy procedure are described. The standard treatment scheme is a concomitant chemoradiation therapy, including 45 Gy (1,8 Gy × 5) pelvic external beam radiotherapy and two courses of 5-fluorouracil and mitomycin-C, followed by a 15 Gy brachytherapy boost with a gap limited to 2 to 3 weeks. Higher irradiation dose for the most advanced cases has not yet demonstrated a therapeutic gain in terms of colostomy free survival. Exclusive brachytherapy for in-situ carcinoma or invasive carcinoma less than 10 mm is not recommended due to a high risk of local recurrence. Pulsed dose rate brachytherapy is an alternative to low dose rate brachytherapy (iridium wires) providing the respect of the recommended dose rate (0.5 to 1 Gy/hour). High dose rate brachytherapy is still under evaluation.     

Préparer la curiethérapie de demain

For more than a century, brachytherapy has been a treatment of choice for delivering a high dose in a small volume. However, over the past 15 years, this irradiation technique has stalled. Even so, brachytherapy allows the delivery of the right dose at the right place by dispensing with target volume motion and repositioning. The evolution of brachytherapy can be based on a road-map including at least the following three points: the acquisition of clinical evidence, teaching and valuation of the procedures. The evolution of brachytherapy will be also impacted by technological considerations (end of the production of low dose rate 192 iridium wires). Regarding the evolution toward a personalized treatment, brachytherapy of the future should take its place as a partner of other modern external beam radiation techniques, be performed by experimented actors (physicians, physicists, technicians, etc.) who received adequate training, and be valued in proportion to the delivered medical service.     

Associations d’hormonothérapie et de radiothérapie pour le cancer de prostate

Combination of radiotherapy and androgen deprivation is now considered as the standard of care for patients with a localized prostate cancer but poor prognosis factors. Two groups of randomized trials have led to this recommendation: some have compared radiotherapy alone versus hormonal treatment and radiotherapy: these trials demonstrated, now with a long follow-up, an improvement in 10-year survival for the combined treatment. Three recent trials compared androgen deprivation alone or combined with radiotherapy; a benefit in survival was also demonstrated in favour of the combination. Some questions remained concerning the optimal duration of hormonal treatment, in view of its potential side effects. Patients in the intermediate prognostic groups could receive a short-term androgen deprivation, but those with a high Gleason score must be treated with a long-term hormonal treatment. Modalities of radiotherapy, regarding volumes and dose must also be précised in the next years.     

Radiothérapie intracérébrale en conditions stéréotaxiques

Stereotactic radiosurgery is used for treating several brain diseases. Radiosurgery is a non-invasive alternative to surgery for brain metastases, and randomized trials are on going to assess the role of radiosurgery. Radiosurgery has been advocated for patients with small benign meningioma or with vestibular schwannoma, but there is no proof of efficacy and safety of radiosurgery in comparison with other treatments. Radiosurgery can obliterate 80-90% of small arteriovenous malformations, but no information exists on the survival of treated compared with untreated patients. The limited information available suggests that radiosurgery should be fully evaluated in well-designed prospective studies.     

Logothérapie,groupe de paroles et analyse existentielle en cours de radiothérapie : expérience pilote d’un centre parisien de radiothérapie

Objective

A pilot study has been carried out to assess the benefit of a pilot support group based on existential analysis and logotherapy (therapy centred on the sense of existentialism), alongside the medical treatment of breast cancer.

Materials and Methods

A group of women under the care of the Hartmann Oncology Institute in the final phase of treatment for breast cancer were selected to take part in the support group during this very specific transition period between being ill and resuming a “normal” life.

Results

Between December 2015 and June 2016, eight women participated in the support group. Results taken from an assessment session and a satisfaction survey completed by all participants demonstrate the importance of talking, the relationships created session after session within the group and the support provided by the synergy between the group and its leaders in order to assert a new lifestyle dynamic — a noodynamic according to the terminology of Viktor Frankl (1905–1997), the psychiatrist who created logotherapy — and to give a new purpose to their life.

Conclusions

The results from the support groups on the quality of life of patients treated for breast cancer are encouraging, and establishing these groups alongside logotherapy would be advantageous for a larger number of patients.