Stereotactic radiotherapy of hepatocellular carcinoma: preliminary results.

Stereotactic radiotherapy (SRT) offers a treatment option for hepatocellular carcinoma (HCC) patients that are not eligible for surgery, embolization, chemotherapy, or radiofrequency ablation. We have evaluated the feasibility, tolerance and toxicity of SRT for 25 HCC patients who were not eligible for these other modalities. The patients (6 women and 19 men) were treated with CyberKnife stereotactic radiotherapy using respiratory motion tracking. All patients had liver cirrhosis with an Eastern Cooperative Oncology Group (ECOG) performance score of less than 2 and pre-treatment Child scores ranging from A5 to B9. A total dose of 45 Gy in three fractions of 15 Gy each was prescribed to the 80% isodose line (95% of the PTV received 45 Gy) and delivered to the target volume over 10 to 12 days. Overall the treatment was well tolerated with two Grade 3 acute toxicities and no acute Grade 4 toxicities. Late toxicity was minimal with all observed late toxicities occurring within the first six months of follow-up. Three hepatic recurrences at a distance from the target and one metastasis were observed. The actuarial 1- and 2-year local control rate was 95% (95% CI: 69-95%). At a median overall follow-up of 12,7 months (range, 1-24 months), six of the twenty-five (24%) patients have died. Overall actuarial survival at 1- and 2-years was 79% (95% CI: 52-92%) and 52% (95% CI: 19-78%), respectively. Our results suggest promising therapeutic efficacy and good clinical tolerance to CyberKnife SRT treatment for HCC patients not eligible for other treatment modalities.

Megestrol acetate versus metronomic cyclophosphamide in patients having exhausted all effective therapies under standard care.

BACKGROUND: To evaluate the antitumour activity and safety of metronomic cyclophosphamide vs megestrol acetate in progressive and advanced cancer patients having exhausted all effective therapies under standard care. METHODS: Patients were randomly assigned to receive orally metronomic cyclophosphamide (50 mg b.i.d) or megestrol acetate (160 mg only daily) until intolerance or progression (RECIST 1.0). The primary efficacy end point was a 2-month progression-free rate (PFR(2m)). According to Optimal Simon's design and the following assumptions, namely, P0=5%, P1=20%, alpha=beta=10%, the treatment is considered as effective if atleast 5 out of 44 patients achieved PFR(2m). RESULTS: Between September 2006 and January 2009, 88 patients were enrolled. Two patients experienced grade 3-4 toxicities in each arm (4%). One toxic death occurred in the megestrol acetate arm as a consequence of thrombosis. The metronomic cyclophosphamide arm reached the predefined level of efficacy with a PFR(2m) rate of 9 out of 44 and a PFR(4m) rate of 5 out of 44. The MA arm failed to achieve the level of efficacy with a PFR(2m) of 4 out of 44 and a PFR(4m) of 1 out of 44. The median overall survival was 195 and 144 days in the metronomic cyclophosphamide arm and megestrol acetate arm, respectively. CONCLUSION: Metronomic cyclophosphamide is well tolerated and provides stable disease in such vulnerable and poor-prognosis cancer patients. This regimen warrants further evaluations.

Inter- and intraobserver consistency in assessing eligibility for bevacizumab (BVZ) in non-small-cell lung cancer (NSCLC) patients with centrally located tumors.

BACKGROUND: Bevacizumab (BVZ) combined with platinum-based therapy is registered for first-line treatment of nonsquamous non-small-cell lung cancer (NSCLC). Patients with centrally located tumors are stated ineligible for BVZ treatment. The goal of this study was to assess the consistency in evaluating eligibility of patients with central tumors for BVZ treatment. MATERIALS AND METHODS: The study group was composed of 150 NSCLC patients with centrally located tumors. Eligibility for BVZ was assessed by chest computed tomography (CT) scan. Eligibility was assessed independently using CT images reviewed on workstations. Inter- and intraobserver variations on 50 randomly extracted patients were estimated through a statistical modeling (multiple correspondence analysis). RESULTS: Discordance in eligibility was found for 82 patients (55%). The interobserver strength of agreement was fair to moderate (average kappa = 0.40). Contrarily, the intraobserver strength of agreement was good to very good (average kappa = 0.74). At multivariate analysis, the risk of discrepancy was essentially related to the assessment of the contact between the tumor and the vessels (odds ratio = 13.3, 95% confidence interval 2.8-62.6, P = 0.001). CONCLUSIONS: The consistency in evaluating eligibility of patients with central tumors for BVZ treatment is weak. The study group indicated more stringent criteria to help physicians in taking the best treatment choice that need however to be prospectively validated.

[GIST: imaging findings]. / GIST: rôle de l'imagerie.

The management and the prognosis of gastrointestinal stromal tumors (GIST) have evolved rapidly with new targeted treatments. The aim of this paper is to assess the role of imaging not only for diagnosis but to quantify treatment response. RECIST criteria, which are the standard in assessment of post chemotherapy response in adult's solid tumors, can not be used in targeted therapy: the changes in lesion structures even if case of increasing volume are more specific to assess tumor response.

[Not Available]. / GIST : rôle de l'imagerie.

S. Taïeb, L. Ceugnart, F. Bonodeau, L. Vanseymortier, A. Adenis The management and the prognosis of gastrointestinal stromal tumors (GIST) have evolved rapidly with new targeted treatments. The aim of this paper is to assess the role of imaging not only for diagnosis but to quantify treatment response. RECIST criteria, which are the standard in assessment of post chemotherapy response in adult's solid tumors, can not be used in targeted therapy: the changes in lesion structures even if case of increasing volume are more specific to assess tumor response.

[Partial breast irradiation: high dose rate peroperative brachytherapy technique using the MammoSite]. / Irradiation partielle du sein: technique de curiethérapie de haut débit de dose après l'implantation peropératoire du dispositif MammoSite.

In the conservative management of breast cancer, radiation therapy delivering 45 to 50 Gy to the whole breast, in 4.5 to 5 weeks, followed by a booster dose of 10 to 20 Gy is the standard of care. Based on the numerous studies which have reported that the local recurrences occurs within and surrounding the primary tumor site and in order to decrease the treatment duration and its morbidity, partial breast irradiation using several techniques has been developed. Partial irradiation may be considered as an alternative local adjuvant treatment for selected patients with favorable prognostic factors. Using external beam radiation therapy, the 3D-conformal technique is appropriate to deliver the whole dose to a limited volume. In UK, an intraoperative technique using a miniature beam of low energy of x-ray (50 Kv) has been developed (Targit). Milan's team have developed an intraoperative electrons beam radiotherapy using a dedicated linear accelerator in the operative room. In USA and Canada the MammoSite has been advised for clinical use in per-operative brachytherapy of the breast. These two last techniques are currently compared in phase III randomised studies to the standard whole breast irradiation followed by a tumour bed booster dose. In this review we will focus on the MammoSite technique and will describe the per-operative implantation procedure, radiological controls ad dosimetric aspects.

[Predictive value of abdominopelvic scan for optimal surgery of ovarian carcinoma]. / Travail original présenté lors de la Société Françaiseurgie d'oncologie Gynécologique des 5 et 6 novembre 1999. Valeur prédictive du scanner abdomino-pelvien pour la chirurgie optimale des carcinomes de l'ovaire.

BACKGROUND: Some patients undergo laparoscopy without optimal debulking surgery as initial treatment for advanced ovarian carcinoma. The amount of residual tumor following primary surgery is an important prognosis factor. Neoadjuvant chemotherapy is a new therapeutic approach. Secondary, optimal surgery could be done in better conditions. PURPOSE: To access the ability of preoperative abdominopelvic CT to predict success of debulking surgery for ovarian carcinoma: less than 1cm of residual tumor size after initial surgery. MATERIALS AND METHODS: We reviewed 39 patients (two stage Ic, 1 stage IIc, 22 stage III and 14 stage IV) operated on for ovarian carcinoma between January 1992 and December 1997. Surgical criteria of inability to perform optimal surgical cytoreduction were compared with abdominopelvic CT done the month before. CT scans were prospectively assessed by radiologist A and retrospectively (3 months to 6 years delay) reviewed separately by radiologists A and B without surgical data. RESULTS: Nineteen patients underwent optimal debulking surgery: 13 no residual tumor and 6 with residual lesions under 1cm. The interreader (0.73) and intrareader (0.9) agreement, worked out by Kappa coefficient, was judged good to very good. The sensitivity of CT was 91% with a specificity of 95%. CONCLUSION: These results allowed us to determine which CT criteria were accurate and reproducible to be a helpful for therapeutic choice and to avoid laparotomy without optimal surgery.

[Predictive value of preoperative abdominopelvic CT for optimal cytoreduction surgery in ovarian carcinoma]. / Valeur prédictive du scanner abdomino-pelvin pour la chirurgie optimale des carcinomes de l'ovaire.

Some patients underwent laparoscopy without optimal debulking surgery as initial treatment for advanced ovarian carcinoma. The amount of residual tumor following primary surgery was an important prognosis factor. Neoadjuvant chemotherapy is a new therapeutic approach. Secondary, optimal surgery could be done in better conditions. The purpose was to access the ability of preoperative abdominopelvic CT to predict success of debulking surgery for ovarian carcinoma: less than 1 cm of residual tumor size after initial surgery. We reviewed 39 patients (2 stages Ic, 1 stage IIc, 22 stages III and 14 stages IV) operated on for ovarian carcinoma between January 1992 and December 1997. Surgical criteria of inability to perform optimal surgical cytoreduction were compared with abdominopelvic CT done the month before. CT scans were prospectively assessed by radiologist A and retrospectively (3 months to 6 years delay) rewiewed separately by radiologists A and B without surgical data. Nineteen patients underwent optimal debulking surgery: 13 no residual tumor and 6 with residual lesions under 1 cm. The interreader (0.73) and intrareader (0.9) agreement, worked out by Kappa coefficient, was juged good to very good. The sensitivity of CT was 91% with a specificity of 95%. These results allowed us to determine wich CT criteria were accurate and reproducible to be a helpfull for therapeutic choice and to avoid laparotomy without optimal surgery.

[Computed tomography-guided transthoracic biopsy after negative fiber-optic endoscopy; apropos of 134 patients]. / Biopsies transthoraciques sous contrôle tomodensitométrique après fibroscopie négative; à propos de 134 patients.

PURPOSE: To evaluate the diagnostic accuracy of transthoracic needle biopsy (TNB) in patients being treated for cancer in order to compare results from small and large pulmonary nodules and to study the efficiency of pathology versus cytology analysis. PATIENTS AND METHODS: 141 consecutive CT-guided TNBs were performed in 134 patients. Cancer had been diagnosed in all cases. From the CT images, nodules were classified as small (< or = 15 mm) (n = 63; 47%) or large (> 15 mm) (n = 71; 53%). RESULTS: There were 16 benign and 118 malignant lesions (92 metastasis, 18 primary, 8 unspecified). There was no statistically significant difference for sensitivity and for prevalence of pneumothorax between small or large nodules. For the 107 true-positive and 16 true-negative results, the cytology examination was positive alone in 41 cases (33.3%), the pathology examination in 24 cases (19.5%) and both in 58 cases (47.2%). CONCLUSION: The diagnostic efficiency of CT-guided transthoracic needle biopsy is as good for small pulmonary nodules (> or = 15 mm) as for larger lesions. This technique is particularly useful in the diagnosis of secondary lesions and does not increase the risk of complications, even in case of small nodules. Ordering both pathology and cytology examinations improves the efficacy of TNB.

[Comparative study of tumor evaluation with computerized tomography and surgery in ovarian cancer]. / Etude comparative de l'évaluation tumorale par TDM et par chirurgie dans le cancer de l'ovaire.

PURPOSE: To evaluate the results of an abdomino-pelvic scan in cancers of the ovary in comparison with surgery. MATERIAL AND METHODS: We reviewed the observations concerning patients operated on for malignant tumors of the ovary between January 1992 and April 1995 in our anti-cancer center. We selected 32 patients who had had both a complete surgical abdominal exploration (laparotomy or laparoscopy) and an abdominal pelvic scan in the preceding months. We divided the abdomen into 33 areas and compared the scan of each with the surgical findings. Two cancer radiologists, including one gynecology specialist, studied the imaging separately. Neither knew the results of the surgical observations. RESULTS: Imaging findings varied with localization tumor size and presence or not of ascites radiologists. For certain localization, detection of lesions was difficult for both readers (pancreas, spleen, stomach), for others, recognition improved with experience (bowel, diaphragm, colon). CONCLUSION: The clinician must be aware of the variability of ovarian cancer assessment by CT scan, particularly if imaging alone is being used to guide treatment.