The standard tangential fields used for breast irradiation do not allow optimal coverage and dose distribution in axillary levels I-II and the sentinel node area.

BACKGROUND: Recent data from ACOSOG Z0011 and NSABP B32 trials suggested no need for axillary lymph node dissection (ALND) in patients with micrometastatic involvement of the sentinel lymph node (SLN). The low rate of axillary recurrence was attributed to the axilla coverage by the tangential fields (TgFs) irradiation and systemic therapy. This study aimed to evaluate dose distribution and coverage of the axilla levels I-II and the SLN area. PATIENTS AND METHODS: One hundred and nine patients were analyzed according to three groups: group 1 (50 Gy; n = 18), group 2 (60 Gy; n = 34) and group 3 (66 Gy; n = 57). Patients were treated using the standard (STgF; n = 22) or high (HTgF; n = 87) TgF. RESULTS: The median doses delivered to level I using HTgF versus STgF were 33 and 20 Gy (P = 0.0001). The mean dose delivered to the SLN area was only 28 Gy. Additionally, the SLN area was totally included in the HTgF in 1 out of 12 patients who had intraoperative clip placement in the SNL area. CONCLUSIONS: TgFs provide a limited coverage of the axilla and the SNLB area. This information should be considered when only TgFs are planned to target the axilla in patients with a positive SLN without ALND. Standardization of locoregional radiotherapy in this situation is urgently needed.

Impact of loco-regional treatment on metastatic breast cancer outcome: a review.

Metastatic breast cancer (MBC) at presentation (Stage IV) is a devastating diagnosis with a poor prognosis and a 5-year overall survival rate not exceeding 20%. The treatment is palliative, and its primary aim is to improve the patient's quality of life. In this context, the benefit of local therapy, considered to have no impact on survival, was to control the local evolution of the disease in order to limit the symptoms. Several publications have challenged this paradigm. These studies, either retrospective single-center or based on population cohorts, compared locoregional treatment to exclusive systemic therapy, which is the gold standard in this situation. The outcomes, marked by inherent biases as in all retrospective studies, mainly related to prognostic factors, albeit suggesting a strong and constant association between locoregional therapy and improvement of metastatic progression-free survival and overall survival. Furthermore, the advances made in the metastatic setting using innovative systemic therapies raise more than ever the interest in locoregional treatment. However, currently we have no data to better define subgroups of patients who would benefit from a strategy that include systematic local therapy. Thus, the important ongoing randomized trials may not only answer some of these issues, but will probably change the practice for many patients with MBC at diagnosis. In this review we will focus on the biologic hypotheses that support the importance of local therapy for MBC patients, review data published in this issue and summarize the ingoing trials.

[Intensity-modulated radiotherapy and involved-node concept in patients with Hodgkin lymphoma: experience of the Gustave-Roussy Institute]. / Optimisation de l'« involved-node radiotherapy ¼ par l'utilisation de la modulation d'intensité dans le lymphome hodgkinien localisé : expérience de l'institut Gustave-Roussy.

PURPOSE: To assess the clinical outcome of the involved-node radiotherapy concept with the use of intensity modulated radiotherapy (IMRT) in patients with localized supradiaphragmatic Hodgkin lymphoma. PATIENTS AND METHODS: Patients with early-stage supradiaphragmatic Hodgkin lymphoma were treated with chemotherapy prior to irradiation. Radiation treatments were delivered using the involved-node radiotherapy (INRT) concept according to the EORTC guidelines. Intensity modulated radiotherapy was performed free-breathing. RESULTS: Forty-seven patients with Hodgkin lymphoma (44 patients with primary Hodgkin lymphoma and three patients with recurrent disease) entered the study from January 2003 to December 2010. The median age was 31 years (range 17 to 62). Thirty patients had stage I-IIA, 14 had stage I-IIB disease and three had relapse. Forty-two patients received three to six cycles of adriamycin, bleomycin, vinblastine and dacarbazine (ABVD). The median radiation dose to patients was 36 Gy (range: 20-40). Protection of various organs at risk was satisfactory. The median follow-up was 57.4 months (range: 5.4-94.3). For patients with primary Hodgkin lymphoma, the 5-year survival and 5-year progression-free survival rates were 96% (95% confidence interval: 80-99) and 92% (95% confidence interval: 78-97), respectively. None of the three patients with recurrent disease has relapsed. Recurrences occurred in three patients: one was in-field relapse and two were visceral recurrences. Grade 3 acute lung toxicity (transient pneumonitis) occurred in one case. CONCLUSION: Our results suggest that patients with localized Hodgkin lymphoma can be safely and efficiently treated using the involved node irradiation concept and intensity modulated irradiation.

[Locally advanced cervical cancer: Should intensity-modulated radiotherapy replace brachytherapy?]. / Complément d'irradiation dans le cancer du col de l'utérus localement évolué : curiethérapie utérovaginale ou radiothérapie conformationnelle avec modulation d'intensité ?

Intensity-modulated conformal radiotherapy (IMRT) is booming as treatment of locally advanced cervical cancer. This technique reduces the doses delivered to organs at risk and, by analogy to the irradiation of prostate cancer, opens the door to the possibility of dose escalation to levels close or similar to those achieved by brachytherapy. To date, several studies comparing IMRT with brachytherapy have been published, often methodologically flawed, concluding sometimes that both techniques are comparable. These results should be taken with extreme caution and should not overshadow the recent advances in brachytherapy with the use of 3D imaging and optimization. Preliminary works also showed that the combination of 3D optimized brachytherapy with IMRT could improve the management of the local disease especially for lesions poorly covered by intracavitary techniques.