Carcinomes épidermoïdes du canal anal traités par association concomitante de radiothérapie et de chimiothérapie. Évaluation des résultats fonctionnels

PURPOSE: To evaluate our results after radiation therapy and concomitant chemotherapy in terms of local control, survival and toxicity in patients with anal cancer. METHODS AND PATIENTS: Between November 1990 and January 2002, 60 patients (pts) were treated with radiation therapy and concomitant chemotherapy. The T-stage according to the 2001 UICC classification were: 2 T1, 26 T2, 25 T3, and 7 T4. There were 20 pts with nodal involvement at presentation. The treatment started with external beam RT (median dose: 45 Gy) and concomitant chemotherapy using 5-fluorouracil and cisplatin during the first week and the fifth week of external beam RT (EBRT). After a rest period of 4 to 6 weeks, a boost of 20 Gy was delivered by EBRT in 58 pts and by interstitial (192)Ir brachytherapy in 2 pts. Mean follow-up were 78.5 months. RESULTS: At the end of RT with concomitant chemotherapy local tumor clinical complete response rate was 83%. Out of 10 non responders or local progression, 5 (50%) were salvaged with abdominoperineal resection (APR). Out of 5 local tumor relapses, 3 were salvaged with APR. The overall local tumor control (LC) rate with or without salvage local treatment were 88%. LC rate with a good anal function scoring (score 0 and 1) was 70%. Among 43 pts who preserved their anus, 98% had a good anal function scoring. The 5-year disease-free survival was 75%. After multivariate analysis, 2 independent predicting factors significantly influenced the disease-free survival: HIV-positive pts (negative vs positive, P=0.032) and clinical tumor response after the first course of radiotherapy (<50% vs >or=50%, P=0.00032). Acute grade 2 or 3 toxicities were low: haematological toxicity in 4 pts and intestinal complication corresponding to diarrhea in 10 pts. Late severe complication was observed in 3 pts: 2 pts with painful necrosis of the anus requiring colostomy and 1 pt with grade 3 rectal bleeding. CONCLUSION: We confirm the good results with RT and concomitant chemotherapy. The clinical tumor response after the first course of RT and concomitant chemotherapy is probably the most important predictive factor on the disease-free survival. For patients with T3 or T4 lesion and tumor regression 相似文献   

Le rôle de la curiethérapie prostatique guidée par imagerie 3D sur le ratio thérapeutique : l''expérience du CHU de Québec

PurposeTo evaluate the impact of adaptative image-guided brachytherapy on therapeutic outcome and toxicity in prostate cancer.Materials and methodsThe 1110 first patients treated at the CHUQ-l'Hôtel-Dieu de Québec were divided in five groups depending on the technique used for the implantation, the latest being intra operative treatment planning. Biochemical disease free survival (5-bDFS), toxicities and dosimetric parameters were compared between the groups.Results5-bDFS (ASTRO + Houston) were of 88.5% and 90.5% for the whole cohort. The use of intra operative treatment planning resulted in better dosimetric parameters. Clinically, this resulted in a decreased use of urethral catheterism, from 18.8% in group 1 to 5.2% in group 5, and in a reduction in severe acute urinary side effects (21.3 vs 33.3% P = 0.01) when compared with preplanning. There was also less late gastrointestinal side effects (groups 5 vs 1: 26.6 vs 43.2% P < 0.05). Finally, when compared with preplanning, intra operative treatment planning was associated with a smaller reduction between planned D90 and the dose calculated at the CT scan 1 month after the implant (38 vs 66 Gy).ConclusionThe evolution of prostate brachytherapy technique toward intra operative treatment planning allowed dosimetric gains which resulted in significant clinical benefits by increasing the therapeutic ratio mainly through a decreased urinary toxicity. A longer follow-up will answer the question wether there is an impact on 5-bDFS.     

L''expérience française de l''utilisation d''un projecteur de source pour la curiethérapie prostatique exclusive par implants permanents d''iode radioactif : faisabilité et données de toxicité aiguë

PURPOSE: To analyse a new technique for prostate brachytherapy with permanent Iodine implants characterized by the use of a seed projector after a 3D dosimetric peroperative treatment planning (FIRST technique). PATIENTS AND METHOD: 395 patients have been treated in France with this technique in six radiotherapy centres between November 2002 and December 2005 for a localized prostate cancer. RESULTS: Thirteen patients (3.3%) developped a urinary retention, and respectively 7.8 and 26.5% an acute RTOG grade 3 and 2 toxicity. The 6-weeks IPSS score was equal or lower to 15 in 73% with a 11 median IPSS value. A failure of the loading with the seed-projector, leading to a manual loading of the seeds, occurred in 9 patients (2.3%) in two centres, directly related to the loading procedure with the seed-projector in 5 cases. The median duration of the procedure was reduced by 30 minutes for the patients treated in 2005. CONCLUSIONS: This multicenter study establishes the feasibility of the routine use of a seed projector for permanent iodine 125 prostate implants with an initial tolerance similar to the best results published for other implants techniques.     

Radiothérapie et sujet âgé

Cancer is a disease that predominantly occurs in older patients who represent a quarter of the population in western countries. Numerous types of cancer are observed in elderly people. Radiotherapy is one of the most powerful treatment against cancer. Most of published studies have demonstrated feasibility of radiotherapy in curative or palliative intent whatever cancer types are considered. Complete geriatric assessment and a multidisciplinary approach are the key points. The purpose of this review is to highlight sights of radiation oncology specifically related to aging. Particular emphasis is placed on logistic and technical aspects of radiation, as dose, irradiated volume and fractionation.     

Place de la chirurgie dans les cancers de la prostate de stades cT3-4 N0M0

The surgical treatment of locally advanced prostate cancer has often been discouraged and in many cases a combined treatment with radiotherapy and hormone-therapy is proposed. Nevertheless, radical prostatectomy is efficient in mono-therapy in the majority of patients with a PSA lower than 20 microg/l, a unilateral stage T3a and a Gleason score lower than 8. Patients with a more advanced local stage or with a less well differentiated tumour should not be excluded from a surgical treatment as an initial option. The majority of them will benefit from a multimodal treatment. This can consist of adjuvant radiotherapy in case of obvious margin positive disease, a salvage radiotherapy in case of PSA relapse during follow-up, or a hormonal treatment in case of PSA persistence after surgery or in cases of advanced lymph node invasion. The urologist must utilise the results of the definitive pathology and of the post-operative PSA levels in order to find the indications where and when additional treatment can be applied. The results obtained after 10-15 years with a radical prostatectomy, eventually combined with radiation or hormonal treatment are excellent concerning the cancer specific survival at long term. Therefore radiotherapy and hormones is not the treatment of choice for all clinical T3 prostate cancers.     

Radiothérapie guidée par l’image avec le Cone Beam CT kV (Elekta™) : expérience du centre Léon-Bérard

Image guide radiotherapy with the Cone Beam CT kV (CBCT-kV) developed by Elekta™ has been implemented at the centre Léon Bérard in November 2006. The treatment procedure is presented and detailed for prostate cancer IGRT and non small cell lung cancer (NSCLC) stereotactic radiotherapy (SRT). CBCT-kV is routinely used for SRT, selected paediatric cancers, all prostate carcinomas, primitive brain tumours and head and neck cancers that do not require nodes irradiation. Thirty-five to 40 patients are treated within a daily 11-hours period. The general procedure for 3D images acquisition and their analysis is described. The CBCT-kV permitted to identify about 10% of prostate cancer patients for whom a positioning with bone-based 2D images only would have led to an unacceptable dose distribution for at least one session. SRT is now used routinely for inoperable NSCLC. The easiness of implementing CBCT-kV imaging and its expected medical benefit should lead to a rapid diffusion of this technology that is also submitted to prospective and multicentric medico-economical evaluations.     

Analyse rétrospective de 108 carcinomes canalaires in situ mammaires traités par association radiochirurgicale

PURPOSE: To evaluate survival and prognostic factors of 108 patients with clinically or mammographically detected ductal carcinoma in situ (DCIS), treated from 1980 to 1996 by complete local excision followed by external irradiation. PATIENTS AND METHODS: The median age was 51 (range 37-80). All the patients underwent surgery consisting of a wide resection of the mammary gland harbouring the tumour. The surgical specimens were sent to the pathologists to get information on histology and margin clearance; all the slides were reviewed by one of us to assess the tumoral diameter. External beam therapy was delivered within 8 weeks after surgery. The prescribed irradiation dose was 50 Gy in 25 fractions to be given in 5 weeks. The median duration of follow-up was 93 months (range 40-173). RESULTS: There were nine patients with local recurrence (8.3%); three patients had local recurrence of DCIS and six patients developed invasive breast cancer. The treatment of local recurrence consisted of mastectomy with or without axillary dissection (eight cases) and quadrantectomy (one case). The 5-year and 10-year ipsilateral recurrence-free rate was respectively 92 and 89%. The 10-year cause specific survival was 100%. In univariate analysis, size>or=10 mm, age<45 years old and margin status were significant P=0,02, P=0,03, P=0,005; margin status was significant in multivariate analysis (P<0,02). CONCLUSION: These results are in keeping with those of the literature. They could be improved by the mass screening campaign, which is going on since January 1990 among women aged 50-74 years.     

Résultats à long terme d''une série de 89 patients suivis pour un sarcome des tissus mous traités par chirurgie conservatrice et trois modalités d''irradiation postopératoire

PURPOSE: To evaluate the outcome of patients treated for soft tissue sarcoma using three different post-operative radiotherapy schedules. METHODS AND MATERIALS: Between 1990 and 2003, 89 patients (median age 50.8 years) presenting with soft tissue sarcoma (located to the limbs for 66 of them) underwent post-conservative-surgery radiotherapy. Pathology was liposarcoma in 35 cases and 54 others tumors. Tumors grades (FNCLCC classification) were 1, 2, 3 or unknown in 29, 32, 19 and 9 cases, respectively. Surgery was considered as complete in 68 patients. Irradiation was normofractionated (NF) in 62 cases, hyperfractionated (BF) in 19 cases and hypofractionated (HF) in 8 cases. For all the patients, median delivered dose was 61 Gy [34-76 Gy]. RESULTS: Median follow-up of alive patients was 73,8 months [3-184]. Five-year local control (LC) and overall survival (OS) rates were 85.5 and 71.2% respectively. According to multifactorial analysis, favourable prognostic factors were for local control, complete surgery (P=0.0075) and for overall survival, complete surgery (P=0.0267), grade 1 tumor (P=0.012) and absence of distant recurrence (P=0.0488). There was no statistical evidence of difference for the five-year LC and OS rates between the patients who received NF, BF or HF. There were few complications and there were comparable in the three groups. CONCLUSIONS: This retrospective serie showed similar results for all the schedules. There is no evidence to recommend bifractionation. Hypofractionation should be used only in selected patients with poor performans status.     

Radiothérapie des cancers de la prostate : évaluation in vivo de la dose délivrée par tomographie conique de basse énergie (kV)

PurposeTo investigate if the regular use of kV-CBCT notably increases the dose delivered to tumor and surrounding healthy tissues.Material and methodsImages were obtained using a Varian? equipment (OBI version 1.3, 645 to 650 projections in 370° to acquire image), and patients were irradiated at source–tumor distance: 100 cm. In vivo measurements were performed using radio-thermoluminescent dosimeters Harshaw-TLD700H (TLD) at skin (anterior–posterior and lateral axis crossing the rotation axis), with a fourth TLD group under the table thanks to a retrolaser. TLD's were calibrated at the kV-CBCT effective energy (64 keV), and the method validated using an anthropomorphic phantom, in which Gafchromic EBT films were also inserted.ResultsThe phantom study showed that the dose distribution depends on the phantom position relative to the axis and that the doses measured at the phantom surface using TLD and films (good agreement) were maximum at the entrance of the anterior–posterior axis. Their arithmetic mean was equal, or a slightly greater than doses measured at mid-thickness of the phantom and at the level of the rectum (OAR). In vivo measurements performed on the five first patients (125 kV-CBCT) yield a mean skin dose per kV-CBCT varying from 5.8 ± 0.1 to 7.3 ± 0.2 cGy on the anterior–posterior axis. Lateral skin doses vary from 3.4 ± 0.2 to 4.5 ± 0.2 cGy.ConclusionDoses delivered by repeated kV-CBCT are not negligible. They should be taken into account, but questions about the RBE to be applied to kilovoltage X-rays are raised.     

Tumeurs malignes de la parotide : prise en charge multidisciplinaire, rôle de la radiothérapie

The low incidence, the wide histological spectrum and the natural, sometimes slow, evolution of malignant parotid gland tumours do not allow to easily establish the impact of their treatments. At present, clinical data come from retrospective cohort analysis, whereas randomized phase II-III trials are confidential. Moreover conclusions from these studies are controversial. We present here the therapeutic highlights of parotid cancers: surgery, with the particular concern of facial nerve preservation; and adjuvant treatment essentially based on radiotherapy. This review focused on adjuvant care explores the indications and the technical aspects of radiation, as well as the role of concurrent chemotherapy.     

Radiothérapie conformationnelle par modulation d’intensité des tumeurs pédiatriques

Approximately 40–50% of children with cancer will be irradiated during their treatment. Intensity-modulated radiotherapy (IMRT) by linear accelerator or helical tomotherapy improves dose distribution in target volumes and normal tissue sparing. This technology could be particularly useful for pediatric patients to achieve an optimal dose distribution in complex volumes close to critical structures. The use of IMRT can increase the volume of tissue receiving low-dose radiation, and consequently carcinogenicity in childhood population with a good overall survival and long period of life expectancy. This review will present the current and potential IMRT indications for cancers in childhood, and discuss the benefits and problems of this technology aiming to define recommendations in the use of IMRT and specific doses constraints in pediatry.     

Radiothérapie du cancer du sein chez le sujet âgé

In Western countries, about 25% of breast cancers (BC) occur in women older than 70 years old. Local control is a crucial step to cure disease, because locoregional relapse (LRR) is a major risk factor of subsequent metastases. After mastectomy, radiotherapy (RT) confirmed a very high value (regardless of age) in several trials and meta-analyses, especially in case of high LRR risk factors (i.e. axillary nodal involvement). Globally, RT reduces LRR rates by 60–70% and also increases long-term survival rates by 8–9%. After breast conserving surgery, several trials and meta-analyses confirmed that RT decreases 10-year local recurrence rates from 20–25 to 5–8%. RT replacement by hormonal treatment leads to a significantly higher LRR rate. Hypofractionated RT schemes could usefully apply to elderly people, but partial breast irradiation techniques are still under investigation. Finally, all elderly fitted women should receive adjuvant RT according to general guidelines with optimal technique in order to avoid cardiotoxicity. Indeed, under-treatment has an unfavourable effect on long-term survival.     

Radiothérapie stéréotaxique de carcinomes bronchiques primitifs : suivi non invasif de la cible en temps réel

PurposeStereotactic radiation therapy using the CyberKnife^® has been introduced in France in 2006. Two treatment modalities are currently available: the first one (Synchrony^®) is a real-time fiducial-based target tracking system, while the other (Xsight Lung Tracking [XLT] System^®) is completely fiducial-free.Patients and methodsSixty-eight patients were treated for a pulmonary tumor between June 2007 and November 2009. Since august 2008, the XLT System^® was used for 26 patients. We report the necessary conditions for the XLT System (position, laterality and size of the tumor), the toxicity and outcome of this treatment.ResultsTwenty-two patients were analyzed. Median follow-up was 6 months (min = 3; max = 16). Local control rate was 100%. The main toxicity was grade grade 1 pulmonary alveolitis (27%). No grade 3 or 4 toxicities were reported.ConclusionThe high local control rate and low toxicity obtained with the CyberKnife^® XLT System^® suggest that such treatment is an alternative for inoperable patients.     

Radiothérapie en conditions stéréotaxiques des gliomes de haut grade : une revue de la littérature

The purpose of this literature systematic review was the use of stereotactic radiotherapy in glioma. Research was performed in Medline/PubMed and associated references found in published articles without publication date limit. The quality of series is variable and many biases can be evidenced. Only two randomized trials have been published using stereotactic radiotherapy for up-front treatment. There is a lack of evidence of survival advantages to use this treatment at the time of diagnosis or relapse. There is also insufficient evidence regarding the benefice/harms in the use of stereotactic fractionated radiation therapy for patients with glioma. No recommendations can be enounced. Stereotactic irradiation as boost in primary diagnosed glioma or relapsed tumour is not associated with survival improvement. For relapsed patients, treatment needs to be discussed according to the other treatment options.     

Radiothérapie guidée par la tomographie conique (cone beam computed tomography) : mise en œuvre et applications cliniques

The kV cone beam CT (CBCT) consists of an X-ray tube and a flat panel detector placed perpendicularly to the treatment beam, allowing the acquisition of hundreds of projections in one rotation of the gantry about the patient. Available in all new linear accelerators, the CBCT provides volumetric imaging in treatment position proving the realization of image- and dose-guided radiotherapy (IGRT and DGRT). The clinical indications correspond to mobile tumours irradiating with high precision required techniques, such as stereotactic, hypofractionated or high dose radiotherapy. The clinical experience is still very limited and concerns mainly prostate, head and neck and lung tumours. The registration and treatment protocols are briefly described. Quality control and training are major issues. CBCT based IGRT is a new technique which needs to be optimized. However, it should provide significant clinical benefit in combination with intensity modulated radiotherapy and new imaging modalities for target delineation.     

Radiothérapie d''un hémangiome massif du foie chez une enfant d''un mois et demi

We report the case of a six-week-old baby who underwent irradiation for a giant hepatic hemangioma. After medical treatment including corticosteroids and interferon, no response was observed. She progressed to respiratory failure, requiring the use of mechanical ventilation. An emergency radiation therapy of the liver was decided. We observed a rapid improvement of the child, with the recovery of autonomous breathing without mechanical ventilation and a normalization of cardiac functions. Two months later, a partial left hepatic embolization was needed due to a progression of a localized blood flow. Six months later, she finally came back home. Cardiac output was normal and hepatomegaly began to regress. One year later, ponderal status is satisfactory, and it remains a localized hepatic right lobe hypertrophy without functional consequence.     

Hémangioendothéliome à cellules fusiformes du pharynx traité par irradiation

Spindle cells hemangioendotheloma generally reaches the extremities. Only one oropharyngeal localisation was described in the literature. We report the observation of a 41 years old patient who was operated twice for this localization. The patient presented in 2005 with a third recurrence with important local extension contraindicating surgical treatment. An external radiotherapy was carried out with a good local control of the lesion. In the light of this observation we will discuss physiopathology of this rare lesion and the various therapeutic options.