Outils pour la prédiction de la réponse tumorale et des tissus sains en oncologie radiothérapie

The impact of curative radiotherapy depends mainly on the total dose delivered homogenously in the target volume. Tumor sensitivity to radiotherapy may be particularly inconstant depending on location, histology, somatic genetic parameters and the capacity of the immune system to infiltrate the tumor. In addition, the dose delivered to the surrounding healthy tissues may reduce the therapeutic ratio of many radiation treatments. In a same population treated in one center with the same technique, it appears that individual radiosensitivity clearly exists, namely in terms of late side effects that are in principle non-reversible. This review details the different radiobiological approaches that have been developed to better predict the tumor response but also the radiation-induced late effects.     

Curiethérapie en France en 2020 : synthèse et perspectives du Groupe curiethérapie de la Société française de radiothérapie oncologique

Because of its principle and its high proof level clinical results, brachytherapy represents a specific irradiation technique for the treatment of primary tumors as well as some local relapses in pre-irradiated area. After a glory period between the 80's and 90's, brachytherapy has progressively lost its attractiveness. In order to provide a practical solution to this deleterious situation, it is important that guardianships, health care payers, patient associations, specialist doctors and radiation oncologists understand the reasons leading to this harmful state as well as the risks concerned. A teaching judged insufficient, non-adapted value and an aging image of brachytherapy represent the three main reasons of this degradation and constitute the three most important challenges conditioning its maintain in the anticancer treatment arsenal. An adapted communication with radiation oncologists themselves but also with the other scientific societies remains crucial as well as with guardianship and patient associations. It is central that brachytherapy could be recognized in order to make it stronger and accessible for all the patients who could need it.     

Carcinomes du nasopharynx Aspects cliniques,indications et résultats de la radiothérapie transcutanée et de la curiethérapie État de la question en 2001

Nasopharynx carcinomas (NPC) are a very special head and neck cancer, in term of epidemiology, clinic and pathology. Endemic disease in South East Asia, undifferentiated nasopharynx carcinoma are very frequent CT scan and NMR allow a better knowledge of the modalities of the clinical presentation. Prognostic factors include local and regional extension, NPC is a wellknown radiosensitive disease with a dose-response curve well established. Modern imaging modalities and modification of the ballistic explain the amelioration of the local control and the diminution of therapeutic sequellae. Brachytherapy is an interesting modalities for the boost and the treatment of recurrent disease. The exact place of 3 D CRT and IMRT is not yet known as modifications of fractionation. Local control for T1T2 tumor is excellent but is related to clinical extension (cranial and neurologic involvement) and nodal extension (supra clavicular N3) and show the interest of combined chemo-radiotherapy protocols.     

Gestion du projet de mise en place de la radiothérapie stéréotaxique intracrânienne au Centre finistérien de radiothérapie et d’oncologie

The Centre Finistérien de radiothérapie et d’oncologie, based in Brest (France), wanted to expand its activity by offering intracranial stereotactic radiation therapy to improve patient care. The desire of the Centre was to invest in this innovative and efficient technique and thus modernize its technical platform and its offer of care. The introduction of intracranial stereotactic radiation therapy requires vigilance for the technical and human organization. Therefore, the Centre prepared the implementation of this technique upstream by a structured and timed preliminary project management.     

Équipements requis pour la mise en œuvre de la radiochirurgie et de la radiothérapie en conditions stéréotaxiques intracrânienne

Since the previous special issue of Cancer Radiothérapie dedicated to radiosurgery in 1998, many important technological and computer developments have improved external beam radiotherapy treatment device performances. Whereas the Gamma Knife^® was the gold standard for intracranial radiosurgery, new linear accelerator developments have led to new possibilities for the clinicians. This article describes quickly the different devices available for cranial radiosurgery or fractionated stereotactic radiotherapy.     

Biomarqueurs inflammatoires et immunologiques de réponse à la radiothérapie

In radiotherapy, the treatment is adapted to each individual to protect healthy tissues but delivers most of time a standard dose according to the tumor histology and site. The only biomarkers studied to individualize the treatment are the HPV status with radiation dose de-escalation strategies, and tumor hypoxia with dose escalation to hypoxic subvolumes using FMISO- or FAZA-PET imaging. In the last decades, evidence has grown about the contribution of the immune system to radiation tumor response. Many preclinical studies have identified some of the mechanisms involved. In this context, we have realised a systematic review to highlight potential inflammatory and immune biomarkers of radiotherapy response. Some are inside the tumor microenvironment, as lymphocyte infiltration or PD-L1 expression, others are circulating biomarkers, including different types of hematological cells, cytokines and chemokines.     

Évolution de la curiethérapie en France et perspectives

During the last decade, the organization of brachytherapy in France moved to 62 units in 173 radiotherapy centres in 2009. More than 7500 patients were treated in 2009, quite exclusively with curative intent, for 80% in public or associated hospitals. The techniques improved to high tech 3D dosimetry and optimization of the dose distribution. Brachytherapy, despite representing only 5% of the treatments by irradiation, is a reference treatment for several tumors.     

Les carcinomes du nasopharynx Les modalités de la radiothérapie et les associations de la radiothérapie et de la chimiothérapie: état actuel et perspectives

Nasopharyngeal carcinoma (NPC) is a highly radiosensitive and chemosensitive. In the patient with locally advanced Humours, the results of conventional radiotherapy are unsatisfactory with significant rates of both local recurrences and distant metastases. The aim of this review is to report the innovative strategies for treatment of the nasopharyngeal carcinoma. Altered fractionation techniques can improve local control. The impact of the innovative techniques, including conformai radiation, stereotactic radiation and IMRT, on survival, must be evaluated in randomised trials. The encouraging early results obtained with concurrent (more than sequential) chemotherapy and radiotherapy must be confirmed in prospective randomized trial in endemic areas.     

Mise en œuvre de la radiothérapie stéréotaxique extracrânienne : enjeux de la formation initiale et continue

Stereotactic body radiation therapy is a rapidly growing advanced treatment technique that delivers high radiation dose with great precision. The implementation of stereotactic body radiation therapy should be associated with a specific initial training and continuing professional education for radiation oncologists and medical physicists. The creation of a French stereotactic body radiation therapy group gathering radiation oncologists (SFRO and AFCOR) and medical physicists (SFPM) is mandatory in order to create dedicated national guidelines, prospective databases and to promote clinical trials in this field.     

Doses dans les organes à risque en radiothérapie conformationnelle et en radiothérapie en conditions stéréotaxiques : la vessie

Bladder dose constraints in case of conformational radiotherapy/intensity-modulated radiotherapy and stereotactic radiotherapy are reported from the literature, in particular from the French radiotherapy society RECORAD recommendations, according to the treated pelvic tumor sites. The dose–volume effect on urinary toxicity is not clearly demonstrated, making difficult to establish absolute dose constraints for the bladder. In case of high-dose prostate cancer radiotherapy, the bladder dose constraints are: V60 Gy < 50% and maximum dose < 80 Gy for standard fractionation and V60 Gy < 5%, V48 Gy < 25% and  V41Gy < 50% for moderate hypofractionation (20 fractions of 3 Gy). In case of prostate stereotactic radiotherapy (five fractions of 7.25 Gy), the most frequent dose constraints in the literature are V37 Gy < 10 cm³ and V18 Gy < 40%. In case of conformational radiotherapy of cervix cancer, postoperative endometrium, anal canal and rectum, the recommendations are V40 Gy < 40% and D2% lower than the prescribed dose.     

Organisation française de la radiothérapie pédiatrique : résultats d’une enquête du comité radiothérapie de la Société française des cancers de l’enfant (SFCE)

PurposeRadiotherapy is a rare indication in paediatric oncology, with 800 to 900 children in treatment per year in France. Child cancers represent approximately 1% of cancers in France and half occur before the age of 5 years. Paediatric radiation requires appropriate tools, local, time and specific training. In France, in 2015, 18 centres are accredited by the French National Cancer Institute (INCa) for this activity.Material and methodsSurvey conducted in February 2015 on the care of children (0 to 18 years) in radiotherapy departments in France. The survey was sent to the radiation oncologists involved in the 18 centres. The questions concerned the qualitative and quantitative aspect, medical and organizational aspects, and the involvement of assistant practitioners in the management of this activity.ResultsSeventeen centres responded. In 2014, 889 children under 18 were treated in radiotherapy departments. These departments are working together with one to four paediatric oncology departments. Regarding access to general anaesthesia: three centres perform one to seven treatment(s) under anaesthesia per year, three centres eight to ten treatments under anaesthesia per year, three centres ten to 24 treatments under anaesthesia per year and nine centres out of 17 use hypnosis techniques. In terms of human resources, in 2015, 29 radiation therapists have a paediatric radiotherapy activity. Involvement of assistant practitioners is growing and specific training are desired. Regarding treatment preparation and delivery, 13 centres have specific paediatric contentions, 14 of 16 centres employ radiation intensity modulated if dosimetry is more satisfying with 11 regularly to the craniospinal irradiation. Radiotherapy on moving areas with respiratory gating or hypofractionation is under developed.ConclusionPaediatric radiation therapy is a specific activity requiring a dedicated management, both in human, organizational, medical and scientific aspects.     

Compréhension/acceptation de la radiothérapie : un dilemme éthique résolu par une éthique de la considération et de la sollicitude

PurposeEthical questions are poorly investigated specifically in radiation oncology. The objective of the study was to identify and understand the main ethical issue in radiation oncology.Materials and methodsA quantitative analysis was based on the answers to a questionnaire of 200 professionals from 22 radiation oncology departments. The questionnaire mainly aimed to characterize the main ethical issue. A monocentric qualitative analysis was based on semi-structured interviews focused on the main identified ethical issue, carried out with eight technologists, and 20 patients undergoing radiotherapy.ResultsThe main ethical issue was the understanding and/or acceptance of the treatment by the patients (71 %), which frequently arises (more than once a month) (52 %), and corresponds to an ethical tension between the principles of respect for autonomy and beneficence (the good as viewed by the patient) as defined by Beauchamp and Childress. The technologists, wish the patient to be fully involved in his treatment, with the even possibility of refusing it. However, excluding paternalism and autonomic relentlessness, the technologists have the feeling of acting for the good of the patients by treating them with radiation, even if the patients are not always aware of it, because they are within a situation of vulnerability. If the hierarchy of principles is a compromise alternative, this problem is finally well resolved by the effective implementation of an ethic of consideration and solicitude, restoring the patient capabilities, i.e. the maximum development of his potentialities in his situation of vulnerability. Beyond the legal dimension, patient information is crucial and must consider the specific temporality of the patient.ConclusionThe main ethical issue in radiation oncology is the understanding and/or acceptance of the treatment involving the development of an ethic of consideration and solicitude.     

Fatigue et radiothérapie Revue de la littérature

Fatigue is a common complaint for the cancer patient during and after radiotherapy, according to the published studies. Fatigue is a subjective symptom mostly underestimated by oncologists and other care givers. Etiology is complex, poorly understood in spite of obvious causes like insomnia, nausea, pain, depression, psychological distress, anemia, hypothyroidism, menopause disturbances, treatment adverse effects. Fatigue presents multifactorial and multidimensional aspects. To evaluate it, many tools can be used as single-item, unidimensional and multidimensional instruments. Practically, the open discussion with the patient throughout radiotherapy is essential to define it. Taking charge fatigue requires its acknowledgement by radiotherapist, treatment of associated symptoms with a multidisciplinary approach.     

Marges en radiothérapie du cancer de la vessie

Radical cystectomy is the gold standard treatment of invasive bladder carcinoma, but conservative treatment is a serious option for selected patients. It comprises a transurethral resection, as complete as possible, before a radiation therapy of the whole bladder and pelvis, with a concomitant chemotherapy. Bladder wall movements during the treatment course lead to the use of wide margins to cover the clinical target volume. Planning target volume margins must be anisotropic to correspond to the mobility of each bladder zone: 10 mm in the inferior portion, 15 mm in lateral directions, and 20 to 25 mm in anterior and superior directions. The development of image-guided radiotherapy and adaptative radiotherapy should lead to a reduction of these margins. Besides, partial bladder radiotherapy is showing encouraging results, by reducing the clinical target volume in well-selected patients.     

Association de radiothérapie et d’hormonothérapie dans la prise en charge des cancers localisés de la prostate : où en est-on ?

Radiotherapy and androgen deprivation therapy play a major role in the management of prostate cancer. Indeed, radiotherapy and hormone therapy are combined in a neoadjuvant and concomitant setting for intermediate risk cancers but also in an adjuvant setting in high risk or locally advanced prostate cancer. The benefice of this association was suggested by preclinical studies and demonstrated later by several randomized trials. However, as these trials were conducted before the era of dose escalation the role of androgen deprivation therapy in this case is less clear. Moreover, as hormonal therapy can lead to a significant morbidity and a decrement in quality of life its indications must be carefully weighed especially in case of intermediate risk cancer witch represent a heterogeneous group with distinct prognostic subgroups.     

Arrêt de la commercialisation des fils d’iridium 192 en France : proposition du groupe de curiethérapie de la Société française de radiothérapie oncologique

In 2014, the production of iridium 192 wires in France ended. Thus brachytherapy departments had to move to high-dose rate and pulsed-dose rate afterloading techniques. Most of them had already made this migration for some indications, based on the habits and investments. The brachytherapy group organised meetings and opened discussions to share the clinical knowledge and answer to the questions raised by this migration. This made it possible to resolve and describe quite all the clinical and technical cases of brachytherapy. The development of high technology included the use of 3D dosimetry and optimisation of dose distribution and fractionation. The teaching policy of new technologies contributes to the improvement of treatment quality. Last but not least, a better reimbursement of brachytherapy is necessary and currently negotiated.     

Immunothérapie et radiothérapie dans la prise en charge du cancer du sein : rationnel et synthèse de la littérature sur les applications cliniques actuelles

The discovery of immunotherapy led to understand the major role of immune system during the tumor process. Conventional treatments, such as chemotherapy, are directly tumoricidal. New drugs are developed to target specifically the immune system to make it regain its ability to recognize and eliminate cancer cells. Radiotherapy is used for a long time for its local action, but its systemic role, based on its impact on immunity, is now better known. Breast cancer was wrongly considered poorly immunogenic and put aside the amazing progress in this new area of treatment. In this article, we would like to present the pre-clinical and clinical rationales to associate immunotherapy to radiotherapy in the management of breast cancer.     

Lymphome de type MALT de la prostate : place de la radiothérapie. Observation et discussion

We report the case of a patient presenting with MALT (mucosa-associated lymphoid tissue) lymphoma of the prostate, who received an irradiation delivering 30.6 Gy in 17 fractions after transurethral resection. With a follow-up of 6 years, he remained alive and free of disease. In view of the literature and this case report, definitive local irradiation should be administered in this rare disease.     

La radiothérapie stéréotaxique peut-elle remplacer la curiethérapie pour les cancers du col utérin localement évolués ? Positionnement de la Société française de radiothérapie oncologique

Brachytherapy is part of the treatment of locally advanced cervical cancers, accounting for about half of the total delivered dose. The benefit of dose escalation is the most important in advanced cases or if the tumor has responded poorly. The use of interstitial implantations makes it possible to reach doses of the order of 85 to 90 Gy (including external beam radiotherapy contribution) in most patients, through image-guided approaches. Brachytherapy delivery is one of the quality criteria for patient care. To date, no data allow us to consider as an alternative the use of external boost through intensity-modulated or stereotactic body radiotherapy. Indeed, the doses delivered to the tumor and the capacity to spare normal tissues remains lower, as compared to what is permitted by brachytherapy. It is therefore appropriate for centers that do not have access to the technique to establish networks with centers where brachytherapy is performed, to allow each patient to have access to the technique. It is also necessary to promote brachytherapy teaching. The issue of reimbursement will be crucial in the coming years to maintain expertise that is today insufficiently valued in its financial aspects, but has a very high added value for patients.