Harmonization of practices between radiotherapy centres in the Nord and Pas-de-Calais regions (France): A three-year evaluation

Purpose

The delineation of volumes of interest can be a source of significant interobserver variability. The purpose of this study was to improve the homogeneity of delineation between oncologist-radiotherapists in the territorial departments of Nord and Pas-de-Calais (France) through discussions of clinical cases and the adoption of common published reference documents.

Institut Curie guidelines on breast target volume delineation for patients treated in lateral position

PurposeTo develop guidelines for and describe the delineation of breast for patients treated in lateral position and to transform this three-dimensional technique based on the virtual simulation to volume-based modern intensity-modulated irradiation technique.Material and methodsIn our department, during the daily delineation, radiation oncologists specialized in breast cancer treatment sought consensus on the delineation of clinical treatment volume of the breast through dialogue based on cases. A radiation oncologist delineated clinical treatment volumes on CT scans of five to 20 patients, followed by a discussion and adaptation of the delineation between all radiation oncologists of the team. The consensus established between clinicians was discussed, corrected and improved. All patients were delineated in treatment position; skin markers were used to visualize the breast tissue after careful palpation.ResultsBreast clinical treatment volume was situated and delineated between pectoral muscle and 5 mm below the skin (dosimetric considerations), within the space outlined by skin markers, that showed the limits of the palpable breast tissue. In lateral position some vessels were very useful to define the limits as rami mammarii (from thoracica interna) for the internal one and thoracica lateralis for the external. This is the first atlas proposed for the delineation of the breast clinical treatment volumes for breast cancer using alternative technique of breast irradiation (lateral).ConclusionThis atlas will be helpful for the volume definition in our daily practice of breast irradiation in lateral position and can open perspectives to develop also atlases for other alternative techniques as treatment in prone position.     

Evaluation of a software for automatic delineation of the mammary gland and organs at risk in patients treated for breast cancer in lateral position

Purpose of the studyThe purpose of this study was to assess the potential for improvement of routine breast and organs at risk contouring in patients treated in the lateral decubitus position using Workflow Box™ (Mirada Medical™, UK) automatic contouring software.Materials and methodsAutomatic contouring of the breast by this software is currently based on an atlas created from isodoses representing 95% of the prescribed dose in a population of patients previously treated at institut Curie. Forty cases of breast cancer (20 right breasts and 20 left breasts) were contoured by three radiation oncologists specialized in breast cancer, allowing the creation of a new atlas in the automatic contouring software. This study assessed the quality of contouring in 20 patients (ten right breasts and ten left breasts) by comparing manual contouring performed by the expert radiation oncologists (reference) with those generated by the old and new atlases developed at Institut Curie. The accuracy of contouring was assessed by overlap volume and the associated standard deviations.ResultsBreast contouring based on the new atlas and by radiation oncologists presented a mean overlap of 0.80 ± 0.09 for the right breast and 0.81 ± 0.06 for the left breast. By comparing volumes of interest contoured by radiation oncologists and those obtained from the old atlas, mean overlap volumes were 0.75 ± 0.08 and 0.74 ± 0.13 for the right and left breasts, respectively. Twenty cases (ten right breasts and ten left breasts) used to create the new atlas were also reprocessed by this same atlas in order to assess the quality of automatic contouring of the breast when the case was already known to the software. The mean overlap volume in this case was 0.84 ± 0.08 for the right breast and 0.83 ± 0.06 for the left breast. Finally, after automatic contouring of organs at risk by means of the new atlas, the mean overlap volume was 0.87 ± 0.04 for the heart and 0.93 for each lung (±0.05 for the right lung and ± 0.04 for the left lung).ConclusionWorkflow Box™ automatic contouring software, based on our new atlas provides reliable and clinically relevant organs at risk and breast contouring. The contours proposed by the software from the new atlas were better than those obtained with the previous atlas based on 95% isodoses obtained from old treatment plans. This software has therefore become more efficient, justifying its use in routine clinical practice for breast cancer contouring in patients treated in the lateral decubitus position. Investigations are currently underway to develop a fully automated process to ensure reliable, robust and operator-independent contouring and breast cancer treatment dosimetry in the lateral decubitus position. Promising preliminary results have already been obtained.     

CT and MRI in target delineation in primary hepatocellular carcinoma

PurposeTo compare the quality of computed tomography (CT) and magnetic resonance imaging (MRI) in target delineation of hepatocellular carcinoma.Patients and methodsThirty-one patients with hepatocellular carcinoma received CT and MRI (including diffusion-weighted imaging [DWI]) before surgery. The maximal measurement on axial imaging and pathologic examination were extracted for statistical analysis.ResultsCT, MRI, DWI-based tumour size correlated well with pathologic sizes, r = 0.974, 0.969, 0.964 respectively. But Wilcoxon signed-ranked test showed that differences did exist. CT overestimated the tumour size by 2.9 mm compared to pathology (95% CI: -13.2 to 7.4 mm). The agreement of MRI-pathology seemed to be worse than CT, with a mean difference of 3.6 mm (95% CI: -14.7 to 7.7 mm). The worst agreement was in DWI-pathology, with a mean difference of 5 mm (95% CI: -17.9 to 7.9 mm). But significant difference was found neither between CT and MRI (P = 0.477) nor between MRI and DWI (P = 0.079).ConclusionsCT and MRI-based tumour size correlated well with pathologic size, but differences did exist. Most of the lesions were overestimated by CT and MRI. CT and MRI were similar in the guidance of target delineation, and DWI had added little value to MRI. A margin of 10 mm around the gross tumour volume to become the clinical target volume is likely not sufficient.     

Intérêt de la tomographie par émission de positons au (18F)-fluorodésoxyglucose pour la planification de la radiothérapie des cancers de l’œsophage localement évolués ou inopérables

Purpose

To study the impact on radiotherapy planning of an automatically segmented target volume delineation based on (¹⁸F)-fluorodeoxy-D-glucose (FDG)-hybrid positron emission tomography–computed tomography (PET-CT) compared to a manually delineation based on computed tomography (CT) in oesophageal carcinoma patients.

Hypofractionated radiotherapy for non-metastatic bone and soft tissue sarcomas

PurposeTo evaluate the efficacy and toxicity of hypofractionated radiotherapy in non-metastatic soft tissue and bone sarcomas.Patients and methodsThirty patients underwent hypofractionated radiotherapy between 2007 and 2015. Overall, 17 patients underwent primary hypofractionated radiotherapy, nine underwent hypofractionated radiotherapy for reirradiation, and four received a boost dose via hypofractionated radiotherapy after external beam radiotherapy. Most common disease sites were head and neck and retroperitoneum. Hypofractionated radiotherapy was administered with a definitive, adjuvant, or neoadjuvant intent.ResultsMedian age was 37 years (range: 11–82 years). Median hypofractionated radiotherapy dose was 35 Gy (range: 20–50 Gy) in three to five fractions. Median follow-up was 21 months (range: 1–108 months). One- and 2-year overall survival rate was 75% and 52%, respectively. One- and 2-year local recurrence-free survival rate was 59% and 48%, with local recurrence rates of 16% and 33% in 1 and 2 years, respectively. Univariate analysis revealed tumour size (P = 0.04), hypofractionated radiotherapy intent (P = 0.016) and reirradiation (P = 0.001) as prognostic factors for local recurrence-free survival. Severe late toxicity was observed in one patient as grade 3 trismus.ConclusionHypofractionated radiotherapy as the primary treatment or for reirradiation has been shown to be safe in the treatment of bone and soft tissue sarcomas. It can provide relatively good local control and survival rates.     

Pre- and postoperative radiotherapy for extremity soft tissue sarcoma: Evaluation of inter-observer target volume contouring variability among French sarcoma group radiation oncologists

Purpose

The purpose of this study was to evaluate, during a national workshop, the inter-observer variability in target volume delineation for primary extremity soft tissue sarcoma radiation therapy.

Siriade 2.0 : outil de formation en ligne à la délinéation en radiothérapie

Purpose

In 2008, the French national society of radiation oncology (SFRO) and the association for radiation oncology continued education (AFCOR) created Siriade, an e-learning website dedicated to contouring.

Radiothérapie des sarcomes mammaires primitifs : étude rétrospective

Purpose

Primary breast sarcomas are heterogeneous tumours derived from non-epithelial mammary gland structures. Although they represent a rare entity, their incidence may increase in the coming years owing to conservative approach considered in the treatment of breast cancer. The aim of this work was to highlight the effect of postoperative irradiation in the treatment of these tumours.

Proposition de sélection et délinéation des volumes cibles anatomocliniques tumoraux et ganglionnaire pour la radiothérapie des cancers de la glande sous-mandibulaire

This article provides a proposal for the selection and delineation of clinical target volumes for the treatment with radiation of submandibular glands tumours. This article does not deal with external radiotherapy indications but specifies the volumes to be treated if radiotherapy is chosen. High-risk and low-risk peritumoral clinical target volumes are described based on the probability of local tumoral spread. High-risk and low-risk clinical target volumes are illustrated on CT-scan slices. A proposal for the selection of nodal clinical target volumeis also proposed.     

Adjuvant management of operated uterine sarcomas: A single institution experience

PurposeThe purpose of this study was to describe the adjuvant management of high grade uterine sarcoma and highlight prognostic factors for overall survival and progression-free survival.Material and methodsBetween 01/2000 and 01/2015, 91 patients undergoing surgery were presented at the multidisciplinary team meeting of our institution. The type of surgery, the anatomopathological features, adjuvant treatments, dates and sites of recurrence were collected. The prognostic value of the various factors was evaluated with the multivariate Cox model.ResultsA total of 50 women with uterine sarcoma were identified and lesions included 43 leiomyosarcomas (86%) and seven high grade sarcomas (14%). Eighteen patients received adjuvant pelvic radiotherapy (36%) and six adjuvant systemic therapy (12%). The median follow-up time was 63 months. Thirty-nine patients (78%) had a recurrence: 22 had only metastatic recurrence (58%), two had isolated pelvic recurrence (5%) and 15 had pelvic and metastatic recurrence (38%). Adjuvant radiotherapy was associated with survival without pelvic recurrence in univariate analysis (P = 0.005, hazard ratio [HR] = 0.15); age greater than 55 years and adjuvant radiotherapy were associated with metastatic free survival in multivariate analysis (P = 0.015, HR = 2.37, and P = 0.013, HR = 0.41 respectively)ConclusionAccording to the results of our series, there is a benefit of radiotherapy after surgery in terms of local control of uterine sarcoma. It is necessary to identify the subgroup of patients who will benefit from an adjuvant radiotherapy in order to provide them with more optimal care.     

A new delineation method research of the clinical target volume for pancreatic cancer adjuvant radiotherapy

PurposeThe purpose of this work was to establish a map model of the local recurrence location after pancreatic cancer resection and to generate a new delineation method of clinical target volume, with the aim to effectively improve the adjuvant radiotherapeutic gain ratio.Methods and materialsThe clinical and imaging data of 48 patients with resected pancreatic head cancer and pancreatic body cancer with local recurrences were collected. Local recurrences were all plotted with reference to the geometric centre of the local recurrent foci. Based on the coordinates of the local recurrences with respect to the celiac artery or the superior mesenteric artery, a three-dimensional local recurrence map model was established on the computed tomography image. The adjuvant radiation clinical target volumes encompassing 90% of all local failures and encompassing 90% of postoperative pancreatic head cancer local failures were created respectively. This new delineation method and RTOG 0848 protocol were applied in five simulated cases, then corresponding types of target volumes and plans were generated for comparison.ResultsThe clinical target volume encompassing 90% of all local failures was generated by expanding the combined celiac artery and superior mesenteric artery contour by 1.4 cm superior, 1.9 cm inferior, 2.6 cm left-lateral, 3.1 cm right-lateral, 1.9 cm anterior and 1.6 cm posterior. The corresponding expansions of clinical target volume encompassing 90% of postoperative pancreatic head cancer local failures were 1.4 cm, 1.4 cm, 2.1 cm, 3.1 cm, 1.6 cm and 2.0 cm. The volumes of “new” target PTV-90_edited, PTV-90_H_edited, and the standard target PTV_edited were 217.64 ± 58.67 cm³, 207.78 ± 50.94 cm³ and 320.72 ± 50.94 cm³ in simulated cases. Comparison showed that the “new” target volumes were much smaller than the standard volumes per RTOG 0848 protocol, and the dose received by organs at risk was also lower in the “new” plans.ConclusionsA majority of postoperative local recurrences in patients with pancreatic head and body cancer are contained within a smaller region surrounding the celiac artery and superior mesenteric artery. The “new” volumes targeting high risk local failures may allow dose escalation and enhanced local control while minimizing radiation-related toxicity.     

Combination of radiotherapy and immune treatment: First clinical data

There is a very strong biological and pre-clinical rationale for combining radiotherapy with immune treatment. Radiation affects all steps in the immune response to antigens and clearly upregulates key-molecules on the cancer cell and in the tumor micro-environment, such as MHC class I antigens, tumor-associated antigens and the creation of neo-antigens as well. In many pre-clinical models, radiation together with the right combination and timing of immune therapy leads to regression of distant metastases, at remote non-irradiated sites of the body, the so-called “abscopal effects”. The combination generally also increases the local tumor control. Although a plethora of clinical trials are ongoing or are being planned, clinical data are sparse and mostly even retrospective. The few published prospective studies nevertheless support a synergy between radiotherapy and immune treatment. At least with checkpoint inhibitors, the side effects of the combined modality treatment do not seem to be significantly higher than of each modality alone. In the coming years, more solid data will surely appear and it is anticipated that radiotherapy will become an integral part of immune therapy.     

Safety and efficacy of intensity-modulated radiotherapy in the management of spermatic cord sarcoma

Purpose

Spermatic cord sarcoma is a rare disease, which management remains controversial due to the lack of guidelines. The standard therapeutic approach is surgical: wide soft-tissue resection with radical inguinal orchidectomy, The diagnosis is made during the analysis of the specimen. The high rate of local recurrence indicates adjuvant radiotherapy of the tumor bed. The aim of this series is to determine the efficacy and safety of postoperative intensity-modulated radiotherapy for spermatic cord sarcomas.

Evaluation of a delineation software for cardiac atlas-based autosegmentation: An example of the use of artificial intelligence in modern radiotherapy

PurposeThe primary objective of this work was to implement and evaluate a cardiac atlas-based autosegmentation technique based on the “Workflow Box” software (Mirada Medical, Oxford UK), in order to delineate cardiac substructures according to European Society of Therapeutic Radiation Oncology (ESTRO) guidelines; review and comparison with other cardiac atlas-based autosegmentation algorithms published to date.Materials and MethodsOf an atlas of data set from 20 breast cancer patients’ CT scans with recontoured cardiac substructures creation according to the ESTRO guidelines. Performance evaluation on a validation data set consisting of 20 others CT scans acquired in the same treatment position: cardiac substructure were automatically contoured by the Mirada system, using the implemented cardiac atlas, and simultaneously manually contoured by a radiation oncologist. The Dice similarity coefficient was used to evaluate the concordance level between the manual and the automatic segmentations.ResultsDice similarity coefficient value was 0.95 for the whole heart and 0.80 for the four cardiac chambers. Average Dice similarity coefficient value for the left ventricle walls was 0.50, ranging between 0.34 for the apical wall and 0.70 for the lateral wall. Compared to manual contours, autosegmented substructure volumes were significantly smaller, with the exception of the left ventricle. Coronary artery segmentation was unsuccessful. Performances were overall similar to other published cardiac atlas-based autosegmentation algorithms.ConclusionThe evaluated cardiac atlas-based autosegmentation technique, using the Mirada software, demonstrated acceptable performance for cardiac cavities delineation. However, algorithm improvement is still needed in order to develop efficient and trusted cardiac autosegmentation working tools for daily practice.     

Cancer du canal anal : à l’ère de la radiothérapie conformationnelle avec modulation d’intensité, questions en suspens

Intensity-modulated radiotherapy makes possible to optimize the irradiation and spare normal tissues. The toxicity remains important with concomitant chemotherapy often associated. The improvement of MRI and PET-CT define more precisely the target volumes, which need a higher dose, but necessitates to respect the rules of contouring. The treatment is uniform whatever the stage but should be individualized based on clinical stage and tumor response. New paradigms concern biology, staging, volumes and doses, fractionation and combined treatments.     

TPF induction chemotherapy followed by concurrent chemoradiotherapy for locally advanced nasopharyngeal carcinoma: Long term results of a Tunisian series

Purpose

We represent in this study the long term results of docetaxel, cisplatin and 5-fluorouracil induction chemotherapy followed by concurrent chemoradiotherapy in Tunisian patients with locally advanced nasopharyngeal carcinoma. The objective of our study is to analyse the efficacy as well as the toxicity of this therapeutic protocol.

Reproducibility of rectal tumor volume delineation using diffusion-weighted MRI: Agreement on volumes between observers

PurposeTo retrospectively evaluate the inter-observer agreement between a radiologist and a radiation oncologist and volume differences, in T2 and diffusion-weighted (DWI) MRI of gross tumor volume (GTV) delineation, in rectal cancer patients.Materials and methodsTwo observers, a radiologist and a radiation oncologist, delineated GTVs of 50 patients on T2-weighted MRI (T2_GTV) and echo planar DWI (DWI_GTV). Observers agreement was assessed using DICE index, Bland-Altman analysis and intra-class correlation coefficient (ICC). Student's t-test was used for GTV comparison.ResultsMedian T2_GTV and DWI_GTV were 17.09 ± 14.12 cm³ (1.92–62.03) and 12.79 ± 12.31 cm³ (1.23–62.25) for radiologist, and 16.82 ± 13.66 cm³ (1.78–65.9) and 13.72 ± 12.77 cm³ (1.29–69.75) for radiation oncologist. T2_GTV were significantly larger compared to DWI_GTV (P < 0.001 and P < 0.001, for both observers). Mean DICE index for T2_GTV and DWI_GTV were 0.80 ± 0.07 and 0.77 ± 0.06. The mean difference between the two observers were 0.26 cm³ (95% CI: ?5.36 to 5.88) and ?1.13 cm³ (95% CI: ?5.70 to 3.44) for T2 and DWI volumes. The ICC for T2 volumes was 0.989 (95% CI: 0.981–0.994) (P < 0.001) and 0.992 (95% CI: 0.986–0.996) (P < 0.001) for DWI volumes.ConclusionDWI resulted in smaller volumes delineation compared to T2-weighted MRI. Substantial and almost perfect agreements were reported for DWI_GTV and T2_GTV between radiologist and radiation oncologist. Due to the fact that DWI could be considered a simple technique for volume delineation for radiation oncologist, DWI could be used to improve quality in radiation planning for an accurate boost volume delineation when a dose escalation is investigated.     

食管癌放射治疗临床靶区勾画的相关研究

放疗靶区的界定是影响食管癌精确放射治疗疗效的重要因素.目前食管癌临床靶区(CTV)的勾画范围仍存在较多争议,尚无统一标准.研究提示病理特征、影像学手段及淋巴结转移规律等因素对食管癌CTV勾画可能有指导作用.新的勾画方式如个体化勾画CTV已成为目前的研究热点.