Radiothérapie en conditions stéréotaxiques : les prérequis

Indications of treatment by stereotactic body radiotherapy are dramatically increasing due to new potential indications. The conditions associated with the treatment delivery are multiple. The first step of the process is crucial. It is related to the validation of the indication proposed during the multidisciplinary meeting as regard the evidence-based proof of the concept. These emerging techniques mainly extracranial stereotactic body irradiation do not benefit from long-term evaluation in terms of efficiency as well as normal tissue late toxicities. Priority should be given to prospective independent clinical trials, validated by an independent scientific committee, performed under a relevant and well dedicated multicentric quality assurance program aiming to improve knowledge and selection of indications. The SFRO is still working with others professionals on the definition of the conditions for the implementation of such treatments and actively collaborates with the authorities to define the appropriate conditions to preserve the quality of the treatment delivery under these specific conditions.     

Prise en charge des adénocarcinomes de la jonction œsogastrique résécables : quel traitement périopératoire ?

Adenocarcinoma of the oesophagogastric junction has an ominous prognosis. Until now, oesophageal adenocarcima care was close to the squamous cell cancer one whereas adenocarcinoma of the cardia was mixed with gastric cancers. Results from randomised studies mixed them without making distinctions. Nevertheless, context, natural history and clinical outcome differ. Five-year survival rate is around 40 %, all stages included. Results from several phase-III studies or meta-analysis allowed to define three therapeutic strategies applicable to adenocarcinoma of the oesophagus and the oesophagogastric junction. In Europe, in the case of a resectable tumour, preoperative chemotherapy became a standard treatment since results from the Magic trial. In the United States, post-operative radiochemotherapy according to the "Macdonald" scheme is used in case of a resected tumour with a R0 surgery. Actually, modern techniques of irradiation could reduce the rate of gastro-intestinal toxicities. The survival benefit from preoperative radiochemotherapy is still very controversial with high rates of postoperative morbidity and mortality. We have performed a review of the litterature with a methodological analysis of data with a high level of evidence in order to advise perioperative treatment guidelines for patients with a resectable adenocarcinoma of the lower oesophagus or gastro-oesophageal junction. Results from pre- or postoperative strategies and the role of radiotherapy will need to be analysed in the future through a randomised study.     

RCMI et voies aérodigestives supérieures : le fractionnement différentiel a-t-il un intérêt ?

For head and neck cancer, intensity-modulated radiation therapy (IMRT) provides benefits in terms of coverage of the target tumour volume and reduction of the dose to organs at risk. Altered fractionation called SMART (simultaneous modulated accelerated radiation therapy) or SIB (simultaneous integrated boost), equivalent to the “concomitant boost” of conventional techniques, provides additional theoretical gain in the therapeutic index and simplifies the practical implementation of the treatment. The impact on tumour control and acute and late toxicities is encouraging but needs to be confirmed by prospective clinical studies with sufficient follow-up. A lot of different protocols have been tested without really bringing out a “gold standard”. However, the current results tend to suggest a SIB/SMART-IMRT moderately accelerated without combined chemotherapy for limited stages (I and II), and SIB-IMRT slightly accelerated with induction and/or concomitant chemotherapy for more advanced stages (III and IV).     

Métastases cérébrales de cancer du sein : traitements systémiques

An increase in the incidence of breast cancer patients with brain metastases has been observed over the last years, mainly because the recent development of new drugs including therapies targeting HER2 (human epidermal growth factor receptor 2) resulted in an increased survival of these patients. With HER2+ patients living longer and the well-known neurotropism of HER2+ tumour cells, the resulting high incidence of brain metastases is not really surprising. Moreover, brain metastases more often occur within a context of existing extracranial metastases. These need to be treated at the same time in order to favourably impact patients’ survival. Consequently, the management of breast cancer patients with brain metastases clearly relies on a multidisciplinary approach, including systemic treatment. A working group including neuro-oncologists, neurosurgeons, radiation oncologists and oncologists was created in order to provide French national guidelines for the management of brain metastases within the “Association des neuro-oncologues d’expression française” (ANOCEF). The recommendations regarding the systemic treatment in breast cancer patients are reported here including key features of their management.     

Adénomes pléomorphes parotidiens récidivants : place de la radiothérapie

Parotid pleomorphic adenoma is the most frequent tumor of salivary glands. The prognosis depends on the recurrences because they could lead to iatrogenic events (facial paralysis). Moreover the risk of malignant transformation increases with the number of local relapses. This article aims at reviewing histological and radiological criteria and the surgical techniques. To improve local control, adjuvant irradiation (in first intention or after recurrence) may be useful but is still controversial for benign tumors in young patients with a risk of radio-induced cancer. We listed studies in which adjuvant radiotherapy was used so as to define its place in the treatment strategy. Prognostic factors were found by some authors. Other studies have to be done before strong evidence-based recommendations are issued.     

Chimioradiothérapie postopératoire des cancers des voies aérodigestives : vers un nouveau standard ?

Head and neck squamous cell carcinomas are frequently diagnosed at an advanced stage. Their treatment remains controversial, and has to be multidisciplinary. External beam radiotherapy is a recognized treatment option after radical curative surgery in order to improve local control. Different adjuvant treatment options have been studied in order to improve the outcome of these patients. We review in this paper the different prognostic factors indicating an adjuvant treatment and the interest of treatment intensification in bad prognostic patients.     

Cancers gastriques et pancréatiques : la (chimio)radiothérapie néoadjuvante remplacera-t-elle la chimioradiothérapie adjuvante ?

For many years, adjuvant chemoradiotherapy remained essential in the therapeutic management of gastric and pancreatic adenocarcinomas. For these tumours, surgical excision, the only hope of offering the patient prolonged survival, is only possible in 20% of cases. The median survival of operated patients is only 12 to 20 months due to the frequency of locoregional and/or metastatic recurrences. For stomach cancers, adjuvant chemoradiotherapy is justified by the results of the phase III trial Intergroup 0116 published by MacDonald et al. The gain in survival was at the cost of significant toxicity. This treatment was supplanted in the early 2000s by perioperative chemotherapy. Currently, neoadjuvant chemoradiotherapy clinical studies are ongoing with the aim of improving treatments observance and tolerance. For pancreatic cancers, the role of adjuvant chemoradiotherapy has long been discussed because of trials with contradictory results. Neoadjuvant radiotherapy has many advantages in terms of efficacy and tolerance. It increases the chances of subsequent complete tumour resection. Several prospective trials are currently ongoing to clarify its place in the therapeutic arsenal.     

Radiothérapie conformationnelle prostatique : quelles marges ?

The planning CT allows the delineation of the prostate (clinical target volume, CTV) but with an imprecision at the apex and the inability to visualize the intraprostatic cancer. MRI enables accurate visualization of the prostate outlines and in some extent the intraprostatic tumour (gross tumour volume [GTV]). The integration of MRI data within the CT remains still complex. Analysis of prostatectomy specimen has guided the definition of a CTV beyond the capsule, depending on pretreatment factors. In practice, the CTV can be defined as follows: prostate-only, for good prognosis tumours; prostate (+ 0 to 5 mm margins, excluding the rectum) and seminal vesicles (possibly limited to 2 cm of their proximal region) for intermediate-risk tumours; prostate (+ 5 mm margins) and seminal vesicles for high-risk tumours. The planning target volume (PTV) should be between 5 mm and 10 mm depending on the space directions, in the absence of image-guidance (IGRT). It could be reduced to 5 mm in case of IGRT. In the adjuvant setting after prostatectomy, the definition of the CTV should follow the recommendations from cooperative groups. It takes into account both the analysis of pattern of local recurrence after prostatectomy, but also the specific histological analysis of the surgical specimen of the patient. The corresponding PTV margin is 6 to 8 mm.     

Esthésioneuroblastome : étude rétrospective et revue de la littérature

PurposeOlfactory neuroblastoma or esthesioneuroblastoma is a rare entity among head and neck neoplasms. In this paper, we report the experience of our institution and compare it with a comprehensive review of the literature.Patients and methodsWe retrospectively analysed clinical and treatment data of patients referred to the Lyon Sud University Hospital (France) for histologically proven olfactive esthesioneuroblastoma.ResultsTen patients treated between 1993 and 2015 have been analysed. Disease stage at diagnosis, according to the Kadish staging system, was C in 90% of cases. Median follow-up was 136 months. Ten-year overall survival was 90%. Five- and ten-year progression-free survival were 70% and 50%. Nine patients (90%) underwent surgical resection first. Seven of the nine patients who underwent resection (77%) received adjuvant three-dimensional (3D)-conformal radiotherapy (n = 7), intensity-modulated radiotherapy (n = 1), or volumetric arctherapy (n = 1). The mean dose to the tumour volume was 61 Gy. None of the patients received elective nodal irradiation. Two patients received concurrent chemotherapy. Five patients (50%) presented with disease recurrence, which was local (n = 1), nodal (n = 2) and cerebral (n = 2).ConclusionOur results are consistent with the literature. Because of the lack of prospective study and the low number of cases in the literature, each institution's experience is of the utmost important to improve standardised management of these tumours.     

Cancer du rectum : volumes cibles de la radiothérapie préopératoire

Preoperative radiotherapy is the standard treatment for locally advanced resectable rectal adenocarcinoma. The total mesorectal excision leads to a dramatic increase of local control rate. Thus, the mesorectal space is the usual field for the spread of rectal cancers cells. It could therefore be considered as the clinical target volume (CTV) in the preoperative conformational radiotherapy. From the anatomical basis and radiological contributions, we propose several CTVs for different locations of rectal carinoma.     

Carrières en oncologie radiothérapie : réflexions croisées SFjRO-SFRO-SNRO

The French Society of Young Radiation Oncologists (SFjRO), the National Union of Radiation Oncologists (SNRO) and the French Society of Oncological Radiotherapy (SFRO) aim to reconcile career opportunities and demographic needs in oncology. In 2021, 932 radiation oncologists (RO) are in regular activity in France, this represents an increase of more than 20% in ten years. Physician distribution is changing in public hospitals, cancer centers and private clinics. Currently one third of ROs works in each sector. In addition, fifteen percent of ROs have a mixed activity. In 2021, 180 young RO (trainees and residents) were questioned by SFjRO board about their training, internship, coaching and career guidance. An interactive communication was organized during the 32nd SFRO Meeting in 2021. It was an opportunity to bring the results of this study. More than 70% RO interviewed answered to the survey, for 55% among them, career choice was difficult. In order to help young ROs in their professional approach, three RO made an oral presentation during this session, about radiotherapy in public hospitals, private centers or with a mixed practice. The aim of this article is to summarize the highlights of the last SFjRO/SFRO session: expectations of young RO, career prospects and trends.     

Résultats thérapeutiques du cancer du cavum : y a-t-il une différence entre enfants et adultes ?

PurposeTo compare therapeutic results of nasopharyngeal carcinoma between adults and children.Patients and methodsThree hundred and seventy seven patients with nasopharyngeal carcinoma received a radiotherapy between 1993 and 2007. Sixty-nine of them were 20 years old or less. Two hundred and sixty eight patients received a chemotherapy (neoadjuvant or concomitant).ResultsOverall survival and disease-free survival at 5 years were 67 % and 59.4 % in all patients, respectively. Overall survival rates at 5 years in children and adults were 66 % and 64 %, respectively (P = 0.17), disease-free survival rates at 5 years were 66 % and 57 %, respectively (P = 0.17). Local failures occurred more frequently in adults than in children (1.4 % versus 14 %). However, metastatic events were frequently seen in children. Late toxicities were important in children, xerostomia was the most common one.ConclusionDespite locally advanced disease in children, therapeutic results were better than in adults but not statistically significant. The use of treatment combination (chemotherapy and radiotherapy) in juvenile nasopharyngeal carcinoma may explain our findings.     

Chimioradiothérapie préopératoire du cancer du rectum : expérience d’un centre

PurposeIn recent decades, the management of rectal cancer has been significantly improved by optimizing the surgical treatment with the total mesorectal excision and the development of neoadjuvant radiotherapy with or without chemotherapy. In this study, we investigated the impact of changes in practice over a period of 15 years in an expert centre.Patients and methodsA monocentric study was conducted retrospectively on cT3-resectable T4 patients who received chemoradiotherapy for a locally advanced rectal adenocarcinoma between 1993 and 2008. We studied sphincter preservation, pathological complete response (ypT0), survival, and toxicities by different concomitant chemotherapy and treatment period.ResultsAmong the 179 patients who had a chemoradiotherapy, 56.4% were received concomitant 5-fluoro-uracil-leucovorin, 28.5% with concomitant capecitabine, and 15.1% with concomitant oxaliplatin and capecitabine. The average dose of radiotherapy was 45 Gy (25 × 1.8 Gy). Five-year disease-free survival was 74.3% and overall survival 68.8%. The rate of local recurrence and distant metastases were 6.1 and 23.6%. In multivariate analysis, concomitant chemotherapy oxaliplatin and capecitabine improved the pathological complete response rate (ypT0; capecitabine: 6%, 5-fluoro-uracil-leucovorin: 10.3%, capecitabine-oxaliplatin: 22.2%), but not significantly (P = 0.12) and with more toxicities, and treatment interruptions. Sphincter preservation rate was not improved significantly during the study period (1993–2004 vs. 2005–2008), but disease-free survival improved from 72.2% up to 87.5% (P = 0.03).ConclusionOur results are consistent with those published in the literature. Concomitant chemotherapy with 5-fluoro-uracil or capecitabine remains the standard scheme. Upfront chemotherapy, before chemoradiotherapy, should be investigated with regard to the predominance of metastasis.