[Clinical trials that have changed our practices 2010-2020]. / Les essais cliniques en radiothérapie qui ont changé les pratiques 2010­2020.

PURPOSE: This article aims to describe and list the clinical trials that have changed our practices in breast cancer, urological cancer, gynecological cancer, cancer of the upper aerodigestive tract and digestive cancer in the last ten years. MATERIAL AND METHODS: We listed and selected the studies published between 2010 and 2020. The articles were identified on the basis of a Medline search with PubMed and knowledge of the authors. RESULTS: Five to six trials were selected in breast cancer, urological cancers, gynecological cancers, cancers of the upper aerodigestive tract and digestive cancers asking the different fundamental questions in radiotherapy. CONCLUSION: Depending on the pathologies, the questions raised over the past 10 years remain fundamental questions such as the place of neoadjuvant treatment, the place of hypofractionation or the type of chemotherapy concomitant with radiotherapy.

[Respiratory synchronization and breast radiotherapy]. / Synchronisation respiratoire et radiothérapie mammaire.

Adjuvant radiation therapy following breast cancer surgery continues to improve locoregional control and overall survival. But the success of highly targeted-conformal radiotherapy such as intensity-modulated techniques, can be compromised by respiratory motion. The intrafraction motion can potentially result in significant under- or overdose, and also expose organs at risk. This article summarizes the respiratory motion and its effects on imaging, dose calculation and dose delivery by radiotherapy for breast cancer. We will review the methods of respiratory synchronization available for breast radiotherapy to minimize the respiratory impact and to spare organs such as heart and lung.

[FMEA applied to the radiotherapy patient care process]. / Analyse des risques a priori du processus de prise en charge des patients en radiothérapie : exemple d'utilisation de la méthode Amdec.

PURPOSE: Failure modes and effects analysis (FMEA), is a risk analysis method used at the Radiotherapy Department of Institute Sainte-Catherine as part of a strategy seeking to continuously improve the quality and security of treatments. PATIENTS AND METHODS: The method comprises several steps: definition of main processes; for each of them, description for every step of prescription, treatment preparation, treatment application; identification of the possible risks, their consequences, their origins; research of existing safety elements which may avoid these risks; grading of risks to assign a criticality score resulting in a numerical organisation of the risks. Finally, the impact of proposed corrective actions was then estimated by a new grading round. RESULTS: For each process studied, a detailed map of the risks was obtained, facilitating the identification of priority actions to be undertaken. For example, we obtain five steps in patient treatment planning with an unacceptable level of risk, 62 a level of moderate risk and 31 an acceptable level of risk. CONCLUSION: The FMEA method, used in the industrial domain and applied here to health care, is an effective tool for the management of risks in patient care. However, the time and training requirements necessary to implement this method should not be underestimated.

[Radiation-related heart toxicity]. / Toxicité cardiaque de la radiothérapie.

The radiotherapy of thoracic cancers exposes the heart to late radiation-induced complications. The physiopathological and clinical consequences of heart irradiation have been mostly studied in patients with Hodgkin lymphoma and breast cancer. The main cause of cardiac morbidity is radiation-induced coronaropathy with a relative risk estimated between 2 and 3 in earlier studies. Preexisting factors of cardiovascular risk, including chemotherapy, potentalize the cardiotoxicity of radiotherapy. Conformational radiotherapy, adapting the ballistics and the energy to the delineated volumes while carefully evaluating the dose-volume distribution in the organs at risk, allowed a drastic reduction in cardiac mortality. This toxicity no longer seems to be significant if the cardiac volume has received less than 30 Gy. Nevertheless, the prolonged life expectancy of cancer patients and the expanding use of new cardiotoxic anticancer drugs underline the persistent need to further reduce the dose delivered to the heart. Indeed, 1 Gy added to the mean heart dose would increase the cardiotoxic risk by 4% (IC 95%: 2-6%, P=0.0002). A strengthened collaboration between the radiation oncologist and the cardiologist aims at detecting and treating long-term complications after thoracic radiotherapy.

[Long-term results and prognostic factors of squamous cell carcinoma of the anal canal treated by irradiation]. / Résultats à long terme et facteurs pronostiques des carcinomes épidermoïdes du canal anal traités par irradiation.

PURPOSE: To analyze the prognostic factors of loco regional control (LRC), specific survival (SS) and sphincter conservation (SC) of patients treated by curative and conservative irradiation for an epidermoid cancer of anal canal in our institution. PATIENTS AND METHODS: From 1976 to 2005, 286 patients (pts) were treated by exclusive radiotherapy (180 pts) or chemo-radiotherapy (106 pts) followed by a brachytherapy boost (233 pts) or external beam radiotherapy boost (24 pts). Forty-three pts were stage I, 154 stage II, 31 stage IIIA and 53 stage IIIB. RESULTS: The mean follow-up was 65 months (range: 1.3-250 months). The 5-years-overall survival and SS rates were 66.4% and 78.1% respectively. In multivariate analysis, tumor size (>or=40 mm) [RR=2.1], node involvement (RR=2.4), and poor response (<75%) to first course irradiation [RR=1.9], local relapse (RR=4.5) and distant metastases were factors of poor prognosis for SS. Five-years-LRC were 71.5% (88% for stage I, 69% for stage II, 77%, for stage IIIA and 60% for stage IIIB). Prognosis factors of LCR were tumor size (RR=2.5), response to first course of irradiation (RR=2.9). SC was 71% at 5 years. Prognosis factors of SC were tumor size (RR=1.9) and response to first course of irradiation (RR=2.4). CONCLUSION: The results of this series are similar to those of the literature. As well as initial tumor extension, response to first course of irradiation was found as prognostic factor on LCR, SS, SC. Our results are similar to other series and brachytherapy seems not to be deleterious. Its impact to local control remains to be evaluated.

[Intensity-modulated radiation therapy for head and neck cancers with bilateral irradiation of the neck : preliminary results]. / Radiothérapie conformationnelle avec modulation d'intensité des cancers des voies aérodigestives supérieures avec irradiation bilatérale du cou: résultats préliminaires.

PURPOSE: To report preliminary results of a prospective study of intensity-modulated radiotherapy (IMRT) for head and neck squamous cell carcinoma (HNC) with bilateral irradiation of the neck. PATIENTS AND METHODS: At the Alexis Vautrin Cancer Center, 23 patients have been treated with IMRT for HNC since January 2002-August 2003. The first 10 patients with a minimum follow-up of 3 months were analyzed. All tumors were oropharyngeal. There were four females and six males, with a mean age of 50 years (range 39-66). Stages were I-II in eight and III-IV in two. CTV1 was microscopic disease and N0 neck (prescribed dose : 50 Gy) and CTV2 was macroscopic disease and the volume at risk (prescribed dose: 66-70 Gy). PTV were CTV + 5 mm. Patient's immobilization consisted of a five-point head neck shoulder thermoplastic mask. Set-up verifications were done by semi-automatically matching portal images and digitized reconstructed radiographs. IMRT used dynamic multileaf collimation. Five patients (group A) received 50 Gy IMRT (two post-operative and three with a brachytherapy boost with a mean dose: 27.5 Gy), and five patients (group B) received 66-70 Gy IMRT (four post-operative). Acute and late normal tissue effects were graded according to the RTOG-EORTC radiation morbidity scoring criteria. RESULTS: With a median follow-up of 7.4 months (range 3-18.5), no patient died or had loco-regional relapse. The displacements were <4 mm in 98% cases. CTV1 and 2 received 95% of the prescribed dose in 100% of the volume. On average the mean dose to the contralateral parotid was 25.5 Gy for group A vs. 31 Gy for group B (P = 0.09). Mean doses <26 Gy were obtained in three of five patients in group A vs. zero of five patients in group B (P = 0.04). Acute skin toxicities were grade 1 in five patients, grade 2 in four and grade 3 in one. Acute mucositis cases were grade 1 in three patients, grade 2 in five and localized grade 3 in two. At 3 months, 50% of the patients had a grade 0-1 late xerostomia. CONCLUSION: The 26 Gy dose limit constraint to the contralateral parotid was easier to satisfy when IMRT was prescribed at a maximum dose of 50 Gy. Acute toxicity is low. The displacements in the mask indicate that it is possible to define the PTV as CTV + 4 mm. This reduction should decrease the mean dose to the parotids. At 3 months, a 50% rate of grade 0-1 late xerostomia encourages the hope of a very low rate at 2 years.