Fiduciels intraprostatiques dans le cadre de la radiothérapie stéréotaxique du cancer de la prostate

PurposeImage-guided radiotherapy for prostate cancer is widely used in radiotherapy departments. Intraprostatic gold fiducial markers are used to visualize prostate position and motion before and during treatment. The aim of this report is to describe our experience of implanting intraprostatic fiducial markers under local anesthesia before hypofractionated stereotactic radiotherapy for prostate cancer and to assess its tolerance and reproducibility.Patients and methodsOver a 6 and a half year period, 226 patients with prostate cancer received a stereotactic radiotherapy using the CyberKnife^® system (Accuray) in our institution. Eighteen patients were treated for recurrence after prostatectomy; these patients were excluded from the study. Among the 208 remaining patients, 94 patients (45.2%) received stereotactic radiotherapy as a boost after external beam radiotherapy (three fractions of 6 Gy); 36 patients (17.3%) were had a re-irradiation (six fractions of 6 Gy) and 78 patients (37.5%) had a exclusive stereotactic radiotherapy (68 patients received five fractions of 7.25 Gy and 11 patients five fractions of 6.25 Gy). Four markers were implanted in all patients using transrectal ultrasound; the procedure was performed under local anesthesia, using transperineal access. The four fiducial markers were implanted in two strands with two fiducial each one, 1 cm apart. In order to follow the recommendations of the image-guided radiotherapy system, the two strands of the two markers were located on the same plane in the middle of the prostate, at least 2 cm apart from the midline. After insertion, correct positioning of fiducials markers was verified by X-ray. Dosimetry scanning was performed after the implantation procedure; prostate position tracking was possible before and during treatment through the kilovoltage incorporated system of the robotic accelerator. Clinical data, X-ray verification and dosimetry scanner have been retrospectively reviewed for all patients.ResultsThe tolerance to procedure was excellent; only four patients (1.8%) described pain related to implant. No urinary side effects were reported. Median time from fiducial implantation to dosimetry scanner was 16 days (4–113 days). Four fiducials were found within the prostate at dosimetry scanner in 181 patients and three in 27 remaining patients. All intraprostatic fiducials were used to track the prostate gland before and during treatment.ConclusionsIntraprostatic fiducial markers implantation is a safe and reproducible procedure that allows us to have reliable prostate information before and during stereotactic radiotherapy.     

Hypofractionated stereotactic radiotherapy for challenging brain metastases using 36 Gy in six fractions

PurposeStereotactic radiosurgery and hypofractionated stereotactic radiotherapy are standard treatments for brain metastases when they are small in size (at the most 3 cm in diameter) and limited in number, in patients with controlled extracerebral disease and a good performance status. Large inoperable brain metastases usually undergo hypofractionated stereotactic radiotherapy while haemorrhagic brain metastases have often been contraindicated for both stereotactic radiosurgery or hypofractionated stereotactic radiotherapy. The objective of this retrospective study was to assess a six 6 Gy-fractions hypofractionated stereotactic radiotherapy scheme in use at our institution for haemorrhagic brain metastases, large brain metastases (size greater than 15 cm³) or brain metastases located next to critical structures.Material and methodsPatients with brain metastases treated with the 6 × 6 Gy scheme since 2012 to 2016 were included. Haemorrhagic brain metastases were defined by usual criteria on CT scan and MRI. Efficacy, acute and late toxicity were evaluated.ResultsSixty-two patients presenting 92 brain metastases were included (32 haemorrhagic brain metastases). Median follow up was 10.1 months. One-year local control rate for haemorrhagic brain metastases, large brain metastases, or brain metastases next to critical structures were 90.7%, 73% and 86.7% respectively. Corresponding overall survival rates were 61.2%, 32% and 37.8%, respectively. Haemorrhagic complications occurred in 5.3% of patients (N = 5), including two cases of brain metastases with pretreatment haemorrhagic signal. Tolerance was good with only one grade 3 acute toxicity.ConclusionThe 6 × 6 Gy hypofractionated stereotactic radiotherapy scheme seems to yield quite good results in patients with haemorrhagic brain metastases, which must be confirmed in a prospective way.     

Fractionated Stereotactic Radiation Therapy for Pituitary Adenomas: An alternative escalating protocol of hypofractionated stereotactic radiotherapy delivering 35 Gy in 5 fractions

PurposeEvaluate efficacy and toxicity of hypofractionated stereotactic radiotherapy (HSRT) for patients treated for pituitary adenoma (PA) with an alternative HSRT escalating protocol delivering 35 Gy in 5 fractions.Material and methodsFrom June 2007 to March 2017, 29 patients with pituitary adenoma were treated in Antoine Lacassagne Cancer Centre with an alternative HSRT protocol. Prescribed dose was 35 Gy in 5 fractions of 7 Gy. Radiographic responses were assessed by annual MRI. Hormone blood samples were evaluated each year after HSRT.ResultsA total of 29 patients aged between 23 and 86 years (median 54 years) were included. Twelve patients received HSRT for recurrent cases and 12 received postoperative adjuvant HSRT, 5 patients did not have surgery. After a median follow-up period of 47 months local control rate was 96%. One patient presented an out-field tumor regrowth 73 months after HSRT. The majority of PA were endocrine-active (18 patients, 62%). After HSRT, 8 patients (44%) presented complete response on initial secretion, 4 patients (23%) presented partial response on initial secretion. Four patients (14%) presented grade 2 or more acute radiation toxicities. One grade 4 visual disorder was observed for one patient.ConclusionsHSRT delivering 35 Gy in 5 fractions represents a feasible treatment and shows promising results to reduce hormonal overproduction and to improve local control in PA.     

Stereotactic radiotherapy for large solitary brain metastases

PurposeTo assess effectiveness and toxicity levels of stereotactic radiation therapy without whole brain radiation therapy in patients with solitary brain metastases larger than 3 cm.Patients and methodsBetween June 2007 and March 2009, 12 patients received fractionated stereotactic radiation therapy and 24 patients underwent stereotactic radiosurgery. For the fractionated stereotactic radiation therapy group, 3 × 7.7 Gy were delivered to the planning target volume (PTV); median volume and diameter were 29.4 cm³ and 4.4 cm, respectively. For the stereotactic radiosurgery group, 14 Gy were delivered to the PTV; median volume and diameter were 15.6 cm³ and 3.7 cm, respectively.ResultsMedian follow-up was 218 days. For the fractionated stereotactic radiation therapy group, local control rates were 100% at 360 days and 64% at 720 days; for the stereotactic radiosurgery group, rates were 58% at 360 days and 48% at 720 days (P = 0.06). Median survival time was 504 days for the fractionated stereotactic radiation therapy group and 164 days for the stereotactic radiosurgery group (P = 0.049). Two cases of grade 2 toxicity were observed in the fractionated stereotactic radiation therapy group, and 6 cases of grade 1–2 toxicity, in the stereotactic radiosurgery group.ConclusionsThis study provides data to support that fractionated stereotactic radiation therapy without whole brain radiation therapy with a margin dose of 3 fractions of 7.7 Gy for treatment of solitary large brain metastases is efficient and well-tolerated. Because of the significant improvement in overall survival, this schedule should be assessed in a randomized trial.     

Postoperative radiotherapy after flap reconstructive surgery in patients with head and neck cancer: A retrospective monocentric study with flap delineation to assess toxicity and relapse

PurposeFlaps are increasingly used during reconstructive surgery of head and neck cancers to improve functional outcomes. There are no guidelines as to whether the whole flap or its anastomotic border should be included in the primary tumour target volume of postoperative radiotherapy to prevent local relapses. Relapse and toxicity rates can increase substantially if the whole flap received full dose. Our aim was to determine whether flaps were included in the primary tumour target volume and to report the patterns of relapse and toxicity.Materials and methodsConsecutive patients in 2014 through 2016, with or without a flap, receiving postoperative radiotherapy were selected in a retrospective monocentric control study. Flaps were homogenously delineated blind to treating radiation oncologists using a flap-specific atlas. Tumour recurrence, acute and late toxicity were evaluated using univariate and propensity score analyses.ResultsA hundred patients were included; 54 with a flap. Median flap volume included in the tumour volume was 80.9%. Twelve patients experienced local recurrences: six with a flap, among whom two within their flap (3.7%). Patients with flaps had larger median tumour volumes to be irradiated (25 cm³ versus 58 cm³, p < 0.001) and higher acute/late toxicity rates (p < 0.001) even after adjustment on biases (more advanced T stage, oral cavity, active smoking in patients with flaps). Locoregional recurrence and survival rates were similar between patients with/without a flap.ConclusionRecurrences within a flap were rare in this series when including the whole flap body in the 60Gy-clinical target volume but inclusion of the flap in the primary tumour target volume increased toxicity. Multicentric studies are warranted.     

Impact dosimétrique de la pose d’un espaceur rectal dans le traitement de cancer de la prostate localisé par irradiation en conditions stéréotaxiques

PurposeStereotactic body radiotherapy (SBRT) of prostate cancer is associated with rectal toxicities, which can be reduced by using a hydrogel spacer. The object of this retrospective study was to show the feasibility of spacer placement under local anesthesia and utility of hydrogel spacer to reduce the dose to the rectal wall.Material and methodsWe collected data from all patients with localised prostate cancer treated with SBRT (40 Gy in 5 fractions) between 2018 and 2020. A hydrogel spacer (SpaceOAR®) was placed depending on the availability of the product. We collected dosimetric data for target volumes and organs at risk. We calculated mean values, which were compared using non-parametric tests.ResultsAmong 35 patients, mean age was 75 years. Seventeen had a spacer placed, with a mean space created of 10 mm. No complication was reported during the intervention. High doses to the rectal wall were significantly lower in spacer group (V38: 0.39 cm³ vs. 0.72 cm³; P = 0.02). PTV were better covered in spacer group (P = 0.07). Doses to the bladder wall were similar in both groups.ConclusionSpacer procedure under local anesthesia was well tolerated. Hydrogel spacer allowed to reduce doses to the rectum while improving PTV coverage.     

Long-term results of permanent implant prostate cancer brachytherapy: A single-institution study of 675 patients treated between 1999 and 2003

PurposeTo analyse long-term overall survival, relapse-free survival and late toxicities in a series of 675 patients treated between 1999 and 2003, with a median follow-up of 132 months.Patients and methodsThe cohort included low-risk patients and a selection of “favourable-intermediate” risk patients. All patients were homogeneously treated using an intraoperative dynamic planning prostate brachytherapy technique, with loose 125 iodine seeds. Hormone therapy, consisting most often of an anti-androgen alone, was given in 393 patients (58%).ResultsThe 10-year overall survival was 92% (95% confidence interval [CI]: 90–94) without a significant difference between the low and the select intermediate-risk groups (P = 0.17). The 10-year relapse-free survival rate for the entire cohort was 82% (95% CI: 79–85), and was significantly higher in the low-risk group than in the intermediate one (87 vs 71%; P < 0.0001). Twenty-six percent of the relapses observed in this series occurred after more than 10 years of follow-up. The 10-year cumulative incidence of grade 3–4 urinary toxicity (whatever the delay and the recovery) was 5.78%. The cumulative incidence of grades 3–4 rectal toxicity in the present series was 1.65% at 10 years. As for sexual toxicity, 61% of our patients retained an erectile capacity at 10 years (with or without oral medication), with age being a major factor.ConclusionWith a median follow-up of more than 11 years, this series appears to confirm the excellent long-term results of low-dose rate prostate brachytherapy, both in terms of survival and in terms of toxicity.     

Patterns of locoregional failure in women with early-stage breast cancer treated by whole breast irradiation in the lateral isocentric decubitus position: Large-scale single-centre experience

PurposeThe purpose of this study was to evaluate locoregional control and describe the patterns of failure in patients with breast cancer receiving whole breast radiotherapy in the isocentric lateral decubitus position technique.Patients and methodsIn a series of 832 consecutive female patients with early-stage breast cancer including invasive and in situ tumours treated by breast-conserving surgery followed by three-dimensional conformal whole breast irradiation in the isocentric lateral decubitus position between 2005 and 2010, all patients who experienced locoregional recurrence were studied. Five-year recurrence-free and overall survival rates were calculated. Regional recurrence mapping patterns were also determined.ResultsThe median age of this series of 832 women was 61.5 years (range: 29–90 years). Various types of fractionation were used: 50 Gy in 25 fractions (17.9%), 66 Gy in 33 fractions (50 Gy in 25 fractions to breast followed by sequential boost to tumour bed to a total dose 66 Gy in 33 fractions.) (46.5%), 40 Gy in 15 fractions or 41.6 Gy in 13 fractions (26.1%) and 30 Gy in 5 fractions (9.5%). With a median follow-up of 6.4 years, only 36 patients experienced locoregional recurrence and no association with the fractionation regimen was identified (P = 0.2). In this population of 36 patients, 28 (3.3%) had “in-breast” local recurrences (77.8%), two had local recurrences and regional lymph node recurrence (5.6%), and six had regional lymph node recurrence only (in non-irradiated areas; 16.6%). The median time to recurrence was 50 months. Complete mapping of patterns of recurrences was performed and, in most cases, local recurrences were situated adjacent to the primary tumour bed. Cases of local recurrences presented a significantly lower distant metastasis rate (P < 0.001) and had a significantly longer overall survival compared to patients with regional lymph node recurrence (P < 0.001). However, multivariate Cox regression analysis showed that the site of recurrence had no significant impact on overall survival (P = 0.14).ConclusionThe results of this study indicate a low local recurrence rate. Further careful follow-up and recording of recurrences is needed to improve the understanding of patterns of recurrence.     

Robotic stereotactic body radiation therapy for tumours of the liver: Radiation-induced liver disease,incidence and predictive factors

PurposeRobotic stereotactic body radiation therapy is a new option to treated unresecable liver tumours. The objectives were to assess the tolerance of this technique, to identify predictive factors for toxicity and evaluate the efficiency of this treatment.Patients and methodsFrom June 2010 to November 2012, robotic stereotactic body radiation therapy was proposed for 56 patients with unresecable hepatocellular carcinomas (23 patients) or hepatic metastases (41 patients). Two or less hepatic lesions, lesion size under 75 mm and WHO score under 3 were selection criteria. The prescribed dose was 45 Gy/3 fractions or 60 Gy/3 fractions. The primary end-point was toxicity, using the radiation-induced liver disease definition and to identify predictive factors. Secondary end-points were in-field local control and overall survival.ResultsThe median follow-up was 12.5 months. The one-year local control rate and the one-year overall survival rate were 64% [CI95%: 48.2 to 76.5%] and 89% [CI95%: 76 to 95%], respectively. For patient treated with a total dose of 60 Gy, no one experienced recurrence. According to the definition we took, radiation-induced liver disease rate was 0 or 9%. A lesion size at least 35 mm was a predictive factor to liver toxicity (P = 0.01).ConclusionUsing robotic stereotactic body radiation therapy, the incidence of radiation-induced liver disease is weak and spontaneously reversible. Prospective studies are required to put in evidence other predictive factors of radiation-induced liver disease and confirm the optimal dose treatment.     

Bénéfice attendu du curage ganglionnaire et de l’exérèse des vésicules séminales pour diminuer la toxicité de la radiothérapie des tumeurs prostatiques de haut risque

PurposeIn case of pelvic lymph node and seminal vesicle dissection followed by prostate cancer intensity-modulated radiotherapy, the objective of the study was to evaluate the dosimetric benefit of reducing the target volume.Patients and methodsA total of 25 patients with high-risk prostate cancer had surgery first followed by intensity-modulated radiotherapy and androgen deprivation. Four treatment planning were simulated for each patient, based on two CT scans performed before and after surgery. The target volumes were: prostate–seminal vesicles–lymph nodes, prostate–lymph nodes, prostate–seminal vesicles and prostate only. The total dose was 46 Gy in the seminal vesicles and lymph nodes, and 80 Gy in the prostate.ResultsCompared to prostate target volume only, the addition of seminal vesicles and lymph nodes multiplied by a factor of 1.6 and 6.5 the target volume, respectively. Decreasing the target volume from prostate–seminal vesicles–lymph nodes to prostate–seminal vesicles, to prostate only decreased the rectal wall mean dose from 49 Gy to 42 Gy, to 36 Gy, and the risk of late rectal bleeding from 4.4% to 3.2%, to 2.4% (P < 0.05), respectively. The bladder wall mean dose decreased from 51 Gy to 40 Gy, to 35 Gy (P < 0,05), respectively. Not irradiating the lymph nodes decreased the absolute risk of diarrhea by 11%.ConclusionLymph node and seminal vesicle dissection before prostate cancer intensity-modulated radiotherapy allows decreasing moderately the risk of digestive toxicity.     

Definitive salvage for vaginal recurrence of endometrial cancer: The impact of modern intensity-modulated-radiotherapy with image-based HDR brachytherapy and the interplay of the PORTEC 1 risk stratification

PurposeData for salvage radiotherapy for recurrent endometrial cancer are limited especially in the era of modern radiotherapy including IMRT and 3-dimensional image-based HDR brachytherapy. Theoretically, modern radiotherapy reduces the dose to critical organs-at-risk and maximizes dose to the target volume, possibly decreasing morbidity and increasing tumor control.Materials and methodsForty-one patients completing definitive salvage radiotherapy for vaginal recurrence of endometrial cancer from June 2004 to December 2013 were retrospectively reviewed. HDR Brachytherapy was completed using image-based planning with contouring/optimization with each fraction to a median dose of 23.75 Gy in 5 fractions. HDR brachytherapy was preceded by external beam radiotherapy predominately using an IMRT technique (90%) to a median dose of 45 Gy in 25 fractions. Toxicity was reported according to CTCAEv4.ResultsAt a median follow-up of 18 months (range: 3–78), the clinical complete response rate was 95%. The 3-year local control, distant control, recurrence free survival, and overall survival were 95%, 61%, 68%, and 67%. Significant predictors of both distant failure and overall survival were primary prognostic factors of depth of myometrial invasion, FIGO stage, and FIGO grade. There was no grade 3+ acute toxicity; the 3-year rate of grade 3+ late toxicity was 8%.ConclusionsSalvage IMRT plus 3-dimensional image-based HDR brachytherapy shows excellent tumor control and minimal morbidity for vaginal recurrence of endometrial cancer. Anticipated salvage rates must be taken in the context of primary risk factors including depth of myometrial invasion, FIGO stage, and FIGO grade.     

Pattern of relapse following three-field lymphadenectomy of esophageal carcinoma and related factors predictive of recurrence

PurposeFor treatment of esophageal carcinoma, the optimal postoperative radiotherapy target volume after three-field lymph node dissection (3-FLD) had not been determined. We analyzed local recurrence pattern of thoracic esophageal carcinoma and risk factors of lymph node recurrence after 3-FLD without prophylactic radiotherapy.Material and methodsWe reviewed 1282 patients with thoracic esophageal squamous cell carcinoma (ESCC) who were treated with 3-FLD without radiotherapy from 2010 to 2018 and analysed local recurrence patterns and risk factors of lymph node recurrence, in order to provide a reference for determination of the radiotherapy target volume for thoracic ESCC.ResultsThe lymph node recurrence accounted for 91.0% of treatment failures. The mediastinal, cervical and abdominal lymph node recurrence accounted for 84.92%, 36.07% and 22.30%, respectively (χ² = 264.776, P = 0.000). The superior, middle and inferior mediastinal lymph node recurrence rates were 67.54%, 27.87% and 0.98%, respectively (χ² = 313.600, P = 0.000). Cervical metastases were significantly associated with N stage and Preoperative cervical lymph node status. Abdominal metastases were significantly associated with the number of preoperative abdominal lymph node metastases (LNM), tumor location and N stage.ConclusionsThe main pattern of local-regional recurrence might be lymph node metastasis after radical 3-FLD without radiotherapy in esophageal carcinoma. The dangerous lymph node recurrence regions included neck, superior and middle mediastinum. The abdominal areas might be irradiated for lower TEC patients with preoperative abdominal LNM.     

Expérience monocentrique de la tomographie par émission de positons à la (18F)-fluorocholine : analyse de son impact sur les indications de traitement local de rattrapage dans la prise en charge des adénocarcinomes prostatiques

PurposeTo assess usefulness of (¹⁸F)-fluorocholine positron emission tomography (PET) for localizing relapse in patients with biochemical relapse from prostate adenocarcinoma and its impact on indications of salvage local therapy.Patients and methodsAn (¹⁸F)-fluorocholine PET coupled with computed tomography was performed in 28 patients with biochemical progression from prostate adenocarcinoma. At the time of (¹⁸F)-fluorocholine PET, median prostate specific antigen (PSA) was 3.0 ng/mL (from 0.34 to 93 ng/mL) and 17 patients (60.7%) received hormone therapy. Eighteen patients from this cohort were potentially candidates to salvage radiotherapy.ResultsA pathologic uptake was shown in 11 patients (39.3%) and 17 patients (60.7%) had no pathologic uptake. Median PSA was 2.4 ng/mL (0.33 to 36 ng/mL) in case of negative (¹⁸F)-fluorocholine PET, versus 6.75 ng/mL (1.21 to 93 ng/mL) in case of pathologic uptake (P = 0.04). Among the 17 patients candidates to salvage radiotherapy, (¹⁸F)-fluorocholine PET helped deciding for salvage radiotherapy in five patients, since it showed only centropelvic pathologic uptake (27.7%). In one patient, it showed metastatic and radiotherapy was contraindicated. After prostatectomy, (¹⁸F)-fluorocholine PET was positive in only one patient candidate to salvage radiotherapy (9.1%), showing anastomotic relapse.Conclusion(¹⁸F)-fluorocholine was positive in about a third of patients with biochemical progression. Its clinical impact is being prospectively investigated.     

Tolerance and efficacy of dose escalation using IMRT combined with chemotherapy for unresectable esophageal carcinoma: Long-term results of 51 patients

PurposeThe optimal dose in esophageal cancer patients treated with definitive chemoradiation (CRT) remains debated. We herein report on the dosimetric results, treatment-related toxicities and long-term outcomes of escalated dose up to 60 Gy delivered with intensity-modulated radiotherapy (IMRT).Materials and methodsAll consecutive patients that received a definitive CRT > 50 Gy for an unresectable esophageal carcinoma between 2010 and 2015 were retrospectively evaluated for this study. Methodology included data base search, delayed toxicity grading, statistical testing including frequency analysis and survival analysis.ResultsA total of 51 patients were irradiated for a squamous cell carcinoma (86.3%) or an adenocarcinoma (13.7%). The median age at diagnosis was 62 years. Seven patients were simultaneously irradiated for another synchronous primary tumor. Forty-six patients (90.2%) received concurrent platin-based chemotherapy. The median prescribed doses were 60 Gy (54–66) and 48 Gy (44.8–56) delivered in 30 (27–35) fractions to the high and the low risks PTV respectively. The mean dose delivered to the lungs was 11.4 Gy (IC 95%: 4.8–19.8), the median volumes receiving up to 20 Gy (V20) and 30 Gy (V30) were 13.5% (3.0–46.0) and 4.6% (0.7–19.8) respectively. The mean dose delivered to the heart was 13.9 Gy (IC 95%:0.3–31.3) with a median V40 of 3.3% (0.0–25.0). One treatment-related death occurred within days after RT completion (neutropenic aplasia). After a median follow-up of 2.7 years (95% CI: 1.9–4.3), the 2-year overall survival, disease free survival and loco-regional control rates were 53.6%, 42.0% and 72.8% respectively. Delayed treatment related-toxicities ≤ grade 3 occurred among 25 patients (62.5%) mostly esophageal stricture (79.2%).ConclusionWe demonstrated in this study that dose escalation using IMRT in combination with platin-based chemotherapy as a definitive treatment for esophageal carcinoma is safe and results in higher loco-regional and control survival when compared to previously reported data.     

Place de l’irradiation stéréotaxique hypofractionnée dans le traitement des métastases cérébrales

PurposeA survey of the literature has been performed to find arguments in order to help the choice between radiosurgery and hypofractionnated stereotactic radiotherapy in the treatment of brain metastases.Patients and methodsA comparison of two groups of brain metastases treated with hypofractionnated stereotactic radiotherapy or radiosurgery, with or without WBRT was performed. Hypofractionnated stereotactic radiotherapy: there were eight series including 448 patients published from 2000 to 2009; treated with 5–6 MV X-Rays, non invasive head immobilization, a margin 2 to 10 mm; 24 to 40 Gy in three to five fractions; a 5 to 8 days duration in six series and 15–16 days in two other series. WBRT (30%) ; radiosurgery: there were 12 series (1994 to 2005) including 2157 patients; an invasive head immobilization, no margin; doses from 10 to 25 Gy; six series over 12 had Gamma Knife radiosurgery and six had Linacs X-Rays. WBRT (30 Gy/10 F/12 days) associated to radiosurgery in several series. The following parameters were compared: median GTV, median survival, 1-year survival rate, local control rate, necrosis and WBRT rates.ResultsHypofractionnated stereotactic radiotherapy series: the parameters were respectively: 0,52–4,47 cm³ (median 2,8 cm³); 5–16 months (median 8,7 months); 68,2–93% (median 82,5%); necrosis rate 3,1%; associated WBRT 30%. Radiosurgery series: the parameters were respectively: 1,3 to 5,5 cm³ (median 2 cm³); 5,5 to 22 months (median 11 months); 71 to 95% (median 85%); 0,5 to 6% (median 2,4%); associated WBRT 58%. Results seem similar in the two groups: Hypofractionnated stereotactic radiotherapy with non invasive immobilization could theoretically treat all brain metastases sizes except lesions < 10 mm (500 mm³). In large volumes, > 4200 mm³ GTV, the toxicity of hypofractionnated stereotactic radiotherapy was not reported, thus it was difficult to compare its results with the published reports of radiosurgery toxicity. WBRT was a confusing parameter. Obviously, this initial survey has important limitations, specifically its methodology.ConclusionRadiosurgery and hypofractionnated stereotactic radiotherapy could be used to treat brain metastases with GTV > 500 mm³ and ≤ 4200 mm³ (Ø 20 mm); for GTV < 500 mm³ (Ø 10 mm) an invasive procedure with radiosurgery is necessary. For GTV > 4200 mm³ (Ø 20 mm), hypofractionnated stereotactic radiotherapy could be proposed, provided further studies, using 4 to 6 Gy fractions, a duration less or equal to 10–12 days and a margin of 2 mm will be performed.     

Hypofractionnement à visée curative dans le cancer de la prostate

Radiotherapy plays a central role in the management of localized prostate cancer, but the total duration of treatment of nearly 2 months poses not only problems of fatigue related to repetitive transports, especially for older patients, but also increases the overall cost of treatment including linear accelerators occupancy and patient transportation. To address this problem, various teams have developed hypofractionated radiotherapy protocols seeking to maintain the same efficacy and toxicity while reducing the total duration of treatment. These hypofractionated protocols require recent techniques such as image-guided radiation therapy (IGRT) and intensity-modulated radiation therapy (IMRT). Single centre series have validated the feasibility of “light” hypofractionation schemes at doses per fraction less than 6 Gy Similarly, different teams have shown the possibility of stereotactic irradiation for delivering “severe” hypofractionation schemes at doses greater than 6 Gy per fraction. Whatever the dose per fraction, the current clinical data support the conclusion that hypofractionated radiotherapy does not increase mid-term toxicity and could even improve biochemical control. Studies with the objective of demonstrating non-inferiority are expected to definitively validate the role of hypofractionated irradiation in the treatment of prostate cancer.     

Could conventionally fractionated radiation therapy coupled with stereotactic body radiation therapy improve local control in bone oligometastases?

PurposeTo describe clinical outcomes of stereotactic body radiation therapy (SBRT) applied alone or as a boost after a conventionally fractionated radiation therapy (CFRT) for the treatment of bone oligometastases.Material and MethodsThis retrospective cohort study included patients treated with SBRT from January 2007 to December 2015 in the Institut de cancérologie de Lorraine in France. The inclusion criteria involved adults treated with SBRT for one to three bone metastases from a histological proven solid tumor and a primary tumor treated, an Eastern Cooperative Oncology Group (ECOG) score inferior or equal to 2. Local control (LC), overall survival (OS), progression free survival (PFS), bone progression incidence (BPI), skeletal related events free survival (SRE-FS), toxicity and pain response were evaluated.ResultsForty-six patients and 52 bone metastases were treated. Twenty-three metastases (44.2%) received SBRT alone mainly for non-spine metastases and 29 (55.8%) a combination of CFRT and SBRT mainly for spine metastases. The median follow-up time was 22 months (range: 4–89 months). Five local failures (9.6%) were observed and the cumulative incidences of local recurrence at 1 and 2 years respectively were 4.4% and 8% with a median time of local recurrence of 17 months (range: 4–36 months). The one- and two-years OS were 90.8% and 87.4%. Visceral metastasis (HR: 3.40, 95% confidence interval [1.10–10.50]) and a time from primary diagnosis (TPD) > 30 months (HR: 0.22 [0.06–0.82]) were independent prognostic factors of OS. The 1 and 2 years PFS were 66.8% and 30.9% with a median PFS time of 18 months [13–24]. The one- and two-years BPI were 27.7% and 55.3%. In multivariate analysis, unfavorable histology was associated with worse BPI (HR: 3.19 [1.32–7.76]). The SRE-FS was 93.3% and 78.5% % at 1 and 2 years. The overall response rate for pain was 75% in the evaluable patients (9/12). No grade ≥ 3 toxicity nor especially no radiation induced myelopathy (RIM), two patients developed asymptomatic vertebral compression fractures.ConclusionThe sole use of SBRT or its association with CFRT is an efficient and well-tolerated treatment that allows high LC for bone oligometastases.     

Intraoperative partial irradiation for highly selected patients with breast cancer: Results of the INTRAOBS prospective study

PurposeTo evaluate our long-term experience on one-day breast intraoperative radiotherapy (IORT) given as sole radiation treatment to selected patients with breast cancer.Methods and materialsInclusion criteria of INTRAOBS study (prospective observational study) were: ER+ T1N0 unifocal ductal carcinoma; absence of lymphovascular invasion or of extensive intraductal component (Scarff-Bloom-Richardson grade III and HER2+++ excluded). Two different linacs were used (20 Gy/1 fraction): one dedicated electron linac (< October 2011), and afterwards a mobile linac (50 kV photons). The primary endpoint was the local recurrence rate (=ipsilateral breast cancer recurrences number). Secondary endpoints were recurrence-free survival (RFS), overall and specific survival, cosmetic results, and patient satisfaction.ResultsOf the present pre-planned analysis for the first 200 patients (median age: 68 years; range, 59–87 years) who received IORT between January 2010 and October 2014 (median follow-up of 53.4 months). A total of 193 patients were still alive. The local recurrence rate was 2.5% (n = 5). The 1- and 5-year local RFS rates were 100% and 95.2%, respectively. At 12 months post-surgery, satisfaction about IORT was excellent for 86.9% of patients. Cosmetic results were considered by patients and physicians as good or very good in 89.4% and 97.3% of cases, respectively.ConclusionsIORT for selected patients with breast cancer shows low recurrence rates, good cosmetic outcomes and excellent satisfaction.