[News in gastrointestinal radiotherapy: The esophageal cancer]. / Actualités en radiothérapie digestive : le cancer de l'œsophage.

Esophageal cancers continue to have a poor prognosis, even if this has improved over the past 25 years due to better management. Pre-operative chemotherapy with Paclitaxel-Carboplatin followed by adjuvant immunotherapy with Nivolumab represents a major advance in the management of locally advanced oesophageal cancer. Pre-operatively, chemo-radiotherapy can be performed in combination with FOLFOX or Paclitaxel-Carboplatin. Several trials are currently ongoing to evaluate the benefit of immunotherapy in non-operable cancers. In contrast, dose escalation in locally advanced non-operable tumors and the combination of pre-operative chemo-radiotherapy with trastuzumab have not been shown to be beneficial.

Intraoperative Radiotherapy for Breast Cancer in Elderly Women.

PURPOSE: To evaluate outcomes and postoperative toxicities after intraoperative radiotherapy (IORT) in elderly women. POPULATION: Women older than 65 years, with infiltrating ductal breast cancer ≤3 cm, expressing estrogen receptor (ER+) without Her2 overexpression, and with negative axillary nodes. TREATMENT: Treatment consisted of partial mastectomy with a sentinel lymph node biopsy (SLNB) procedure; in case of positive SLNB, IORT was cancelled. IORT consisted in a total dose of 20 Gy in 1 fraction delivered at the surface of the applicator with the Intrabeam® technique. RESULTS: IORT was planned to be administered to a total of 225 patients but was cancelled for 34 patients during surgery. Thus 191 patients were analyzed; mean age was 76 years, with 57 patients (30%) >80 years. Despite inclusion criteria, 15 had lobular carcinoma and 7 were triple negative. With a median follow-up of 40 months, we observed only 1 local recurrence, located in the skin over the initial tumor. The 5-year local relapse rate was 1.7%. A wound healing delay (>15 days) was observed in 21 patients (11%). Sixty-six patients (35%) had postoperative complications, mainly grade 2, resolving within a few days. Two patients needed surgical drainage for local abscesses. Long-term (>1 year) cosmetic outcome was evaluated in 120 patients and was judged excellent or good in 102 (91%). CONCLUSION: IORT can be safely given to elderly women, with a good local control rate and without major toxicities.

[Place of radiotherapy in the treatment of cutaneous carcinomas]. / Place de la radiothérapie dans le traitement des carcinomes cutanés.

Basal cell carcinomas and cutaneous squamous cell carcinomas are among the most common cancerous tumors in the world. Their treatment is most often based on surgery. Adjuvant radiotherapy may be indicated in case of risk factors for recurrence or as an alternative to surgery if surgery is not feasible due to the patient's advanced age and/or co-morbidities or as an alternative to potentially mutilating surgery. Radiotherapy is also part of the therapeutic arsenal for rarer skin tumors such as Merkel cell carcinoma, cutaneous lymphomas, Kaposi's disease and cutaneous adnexal carcinomas.

Combination of chemotherapy and radiotherapy: A thirty years evolution.

Chemoradiotherapy is now considered the standard of care for many locally advanced diseases. Cytotoxic drugs have been largely evaluated in this setting, with cisplatin and 5FU the most often used drugs. A large amount of pre-clinical studies has demonstrated the synergy between both modalities. Concomitant administration seems the more beneficial in many diseases. Emergence of new approaches, combining targeted therapies and radiotherapy (RT) is now a reality. The main example is the association of cetuximab and RT in head and neck carcinomas, even if, 14 years after the initial publication, the best way to use it is still unknown. New compounds as inhibitors of DNA-repair or immune checkpoints are under investigation and showed early promising results.

Rationale for hypofractionation.

Fractionation was established more than fifty years ago as the best way to obtain a differential effect between tumors and normal tissues. However, new technologies allowed today to spare critical organs from the radiation fields. And so protracted courses of irradiation are no longer required. Hypofractionation have clear practical advantages over classical fractionation: it saves the patient time; it saves money for public health system; it reduces pressure on radiotherapy units. In several localization, it has proved to be as efficient as classical fractionation without increasing late effects. In prostate cancer, some radiobiological considerations argue in favor of a better efficiency, but clinical trials did not demonstrated differences in biological control. In conclusion, for all diseases where hypofractionation was demonstrated efficient, it must be fully implemented. Invoice procedures must be adapted to maintain a sufficient level of reimbursement of radiotherapy centers.

[Follow-up after rectal cancer treatment]. / Surveillance après un cancer du rectum.

Along with the surgeon, the gastroenterologist and the general practitioner, the radiation oncologist is involved in the follow-up of patients with rectal cancer treated by radiation. Post-treatment follow-up is recommended by major professional expert groups and consists of clinical examination, monitoring of carcinoembryonic antigen, colonoscopy and computed tomography of the abdomen and pelvis. Three recent large phase III randomized trials demonstrated a lack of survival benefit from intensive follow-up strategies in comparison with minimal follow-up. However, a follow-up program is not only important for the detection of an early disease relapse but it can be also used for the identification and the management of long-term toxicity and sequalae related to rectal cancer treatment.

Anti-PD-1 immunotherapy in combination with sequential involved-site radiotherapy in heavily pretreated refractory Hodgkin lymphoma.

The purpose of this study was to assess efficacy and tolerance of anti-programmed death (PD)-1 immunotherapy in combination with sequential involved-site radiotherapy in heavily pretreated refractory Hodgkin lymphoma. In this case series, we reported the outcome of four heavily pretreated patients with refractory Hodgkin lymphoma treated by anti-PD-1 immunotherapy and involved site radiation therapy. After a median follow-up of 13-month, all patients were alive with complete metabolic response. After radiotherapy, all four patients experienced lung toxicity, which was resolved after antibiotherapy with or without corticosteroid treatment. Anti-PD-1 immunotherapy followed by involved-site radiotherapy is feasible and showed very encouraging results in heavily pretreated patients.

The sentinel lymph node of breast cancer and the radiation oncologist.

If the indications of sentinel lymph node biopsy and axillary lymph node dissection have been the subject of many trials, the indications of radiotherapy, in the absence of axillary lymph node dissection are a matter of debate. We reviewed the available literature on this topic and tried to draw some practical applications. In case of negative result of a sentinel lymph node biopsy, patients could be viewed as having pN0 disease and indications of adjuvant radiotherapy based on this paradigm. However, when the result of a sentinel lymph node biopsy was positive and no axillary lymph node dissection performed, indications of adjuvant radiotherapy are not so clear. For example, micrometastases could indicate a nodal irradiation as in the AMAROS trial, or not as in the IBCSG trial. Indications of postmastectomy radiotherapy are also not clearly defined in this setting. In the end, a clinical proposal was designed, emphasizing the unanswered questions.

Endoluminal brachytherapy: Bronchus and oesophagus.

Endobronchial brachytherapy could be proposed in case of endoluminal tumours either as a palliative or a curative treatment. As a curative treatment, endobronchial brachytherapy could obtain a high local control rate in case of limited disease. In palliative setting, endobronchial brachytherapy improved thoracic symptoms in more than 80% of cases, but it is less efficient than external beam radiation therapy for palliation. It could be also proposed to maintain the airway open after laser therapy. Oesophageal brachytherapy is a valuable option as a palliative treatment, underused at this time. It causes less side effects and a better quality of life compared to self-expanded metallic stents. For a curative aim, there is today no demonstration that a combination of external beam radiotherapy and oesophageal brachytherapy give better results than external beam radiotherapy alone in locally advanced tumours. For superficial diseases, the combination of external beam radiotherapy and oesophageal brachytherapy seems, on the contrary, promising.

Outcomes of radiation therapy of indolent cutaneous B-cell lymphomas and literature review.

BACKGROUND: Primary cutaneous B-cell lymphomas represent approximately 25% of primary cutaneous lymphomas. Follicular centre cell lymphomas (PCFCL) and marginal zone lymphomas (PCMZL) are the two histological subtypes that present an indolent evolution. Radiotherapy is one of the recommended treatment options with few series reported. OBJECTIVE: This study aimed to evaluate radiotherapy outcomes in term of overall survival (OS) and disease-free survival (DFS) for patients suffering from a PCMZL or PCFCL, to search for predictive factors of recurrence, and to evaluate chronic and aesthetics adverse events and patient's satisfaction. METHODS: Patients treated with contact low energy radiotherapy for a PMZCL or PCFCL from April 2009 to June 2017 in Saint Louis hospital were retrospectively analysed. Total dose ranged from 18 to 30 Gy. Objective response (OR) rates, DFS and OS as patterns of recurrence according to radiation fields were analysed. Univariate analysis of DFS has been performed according to clinical and biological parameters. Acute toxicity, long-term adverse events and satisfaction were collected via individualized questionnaires. RESULTS: Forty-six patients were included. Median follow-up was 43.5 months. OR was achieved for 100% of cases. Recurrence occurred in 39% of cases. Median DFS was 44 months. Three-year DFS and 5-year DFS were 56% and 51%, respectively. OS at 3 and 5 year was 100%. Only sex was significantly associated with DFS. Acute AEs occurred in 48% of cases without grade 3 and 4. 55% reported some moderate aesthetic sequelae for long-term AEs. 97% were satisfied with treatment. CONCLUSION: This study confirms the good risk-benefit of radiotherapy for the treatment of primary cutaneous indolent B-cell lymphomas due to the high response rate and a long DFS. No significant factor for recurrence was identified, except female sex. Long-term aesthetic evaluation was good or excellent for most of the patients.

[Radiotherapy for localized gastric and orbital MALT lymphomas]. / Radiothérapie des lymphomes malins non hodgkiniens localisés de type MALT (gastriques et de la région orbitaire).

Primary gastric and orbital MALT lymphomas are both low grade (indolent) B-cell non-Hodgkin's lymphomas. Traditionally, these tumors are radiosensitive and have a good prognosis. In localized orbital and stages IE-IIE gastric MALT lymphomas without Helicobacter pylori infection or in case of persistent H. pylori infection after eradication therapy, several retrospective studies have shown that radiotherapy was an effective and well-tolerated treatment.

[Radiotherapy in elderly patients, recommendations for the main localizations: Breast, prostate and gynaecological cancers]. / Radiothérapie chez la personne âgée, recommandations pour la pratique clinique pour les principales localisations : cancers du sein, de la prostate et gynécologiques.

Modifications of radiotherapy indications or schedules because of age could be discussed in view of a different evolution of the disease or because of specific toxicities. One important aim is to decrease the number of hospital transports. For breast cancer, the rate of local relapse after lumpectomy is lower in old patients; moreover, characteristics of the disease are often more favourable (hormonosensitivity, low grade). However, adjuvant irradiation decreases significantly the incidence of breast relapse and must be systematically proposed. Hypofractionnated schedules must be recommended; limited data are available for accelerated partial breast irradiation in old women and these techniques must not be used in routine. For low or intermediate risk prostate cancer, assessment of comorbidities is crucial before considering any invasive treatment. A life expectancy of at least 10 years is required if a curative approach, potentially toxic is proposed. In this case, radiotherapy is often the good choice, giving less sequelae than surgery. The indication of androgen deprivation must take into account cardiovascular and bone history. Management of gynaecological cancers must follow the same recommendations as in young women. Exclusive postoperative brachytherapy must be recommended in early stage endometrial carcinomas. Brachytherapy must be also systematically integrated in the radiotherapy program for cervix cancers, even in old women.

[Ductal carcinoma in situ treated with radiation therapy and additional boost]. / Carcinomes canalaires in situ du sein traités par chirurgie conservatrice et irradiation avec complément dans le lit opératoire.

PURPOSE: Women with ductal carcinoma in situ are treated with breast-conserving surgery and radiation therapy. The impact of an additive boost radiation is under evaluation. PATIENTS AND METHODS: All women treated for ductal carcinoma in situ with breast-conserving surgery and whole breast radiation therapy at a total dose of 45Gy with a boost radiation from 1990 to 2008 have been included in this retrospective monocentric retrospective study. RESULTS: We included 171 patients. Boost radiation to the surgical bed was delivered by brachytherapy in 66 patients (39%), by direct en-face electron beam in 86 patients (50%), and by tangential fields using photon beams in 19 patients (11%). Median follow-up was 95.1months. Eight local relapses (4.6%) have occurred. The 10-year local recurrence-free survival rate was 97%. The 10-year overall survival rate was 98%. On multivariable analysis, brachytherapy (P=0.05; HR=5.15; IC=1-26.3) was associated with a reduction risk of local recurrence-free survival. CONCLUSION: In our experience, women treated for a ductal carcinoma in situ with breast-conserving surgery and whole breast radiation therapy with a boost radiation have a high 10-year local recurrence-free survival rate.

Intensity modulated radiation therapy in nasopharyngeal carcinoma.

Radiation therapy (with associated chemotherapy) is the standard treatment for nasopharyngeal carcinoma. Conformal intensity-modulated radiation therapy is a new and particularly interesting technique for these tumors, due to their complex volumes close to many critical organs. Better dosimetric results and improved protection of adjacent healthy tissue have been shown compared with conventional 2D or 3D radiation therapy, with significantly reduced side-effects, notably xerostomia. Excellent local control rates have been reported.

[Radioanatomy of rhinopharyngeal carcinoma]. / Radioanatomie des cancers du rhinopharynx.

Rhinopharyngeal cancer is one of the best indications for conformal radiotherapy with modulated intensity. Due to the high dose gradient, accurate delineation of target volumes and organs at risk is a critical success factor with this technology. This requires a good knowledge of rhinopharyngeal radioanatomy and optimal imaging techniques.