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The incidence of primary hepatic tumours is increasing and the reference treatments by liver transplantation or surgical resection do not allow to compensate for this increase because of the lack of grafts, or the low proportion of initially resectable tumours. The challenges for radiotherapy of primary liver tumors are multiple: physical, biological, medical and technological. Liver stereotactic body radiotherapy is sometimes the only local treatment option and is progressively finding its place for these tumors, even if the recognition of the indications would deserve a better standardization of international recommendations. The heterogeneity of practices and techniques is a major obstacle to the development of randomized studies, despite the excellent oncological results published. The latest ASTRO 2022 guidelines, the recent publication of the guidelines from the French society for radiation oncology on external radiotherapy and brachytherapy procedures ("RecoRad™ 2.0"), and the inclusion in prospective clinical trials will help to homogenize protocols and improve recognition of the technique. The first data from the new techniques of adaptive radiotherapy and MR-guided radiotherapy, whose objectives are to improve targeting and reduce liver or gastrointestinal toxicity, confirm the excellent results of liver SBRT and allow the potential indications to be extended to locations that were previously difficult to treat.

The French Society of Young Radiation Oncologists (SFjRO), the National Union of Radiation Oncologists (SNRO) and the French Society of Oncological Radiotherapy (SFRO) aim to reconcile career opportunities and demographic needs in oncology. In 2021, 932 radiation oncologists (RO) are in regular activity in France, this represents an increase of more than 20% in ten years. Physician distribution is changing in public hospitals, cancer centers and private clinics. Currently one third of ROs works in each sector. In addition, fifteen percent of ROs have a mixed activity. In 2021, 180 young RO (trainees and residents) were questioned by SFjRO board about their training, internship, coaching and career guidance. An interactive communication was organized during the 32nd SFRO Meeting in 2021. It was an opportunity to bring the results of this study. More than 70% RO interviewed answered to the survey, for 55% among them, career choice was difficult. In order to help young ROs in their professional approach, three RO made an oral presentation during this session, about radiotherapy in public hospitals, private centers or with a mixed practice. The aim of this article is to summarize the highlights of the last SFjRO/SFRO session: expectations of young RO, career prospects and trends.

The literature review shows a low adhesion of urologists to the recommendations of learned societies in the imaging work-up of localized prostate cancer (CaP), especially for low and intermediate risks of the D'Amico classification. We analyzed the adhesion of urologists in the Hérault region (France) to the CCAFU 2016/2018, 2018/2020 recommendations.From the Hérault Onco Urology Registry (RHESOU) database, we identified localized CaP diagnosed between 01/01/2017 and 31/12/2019, and then classified them into 3 distinct risk groups according to the D'Amico classification. We compared the imaging workup performed by each patient to the CCAFU 2016/2018, 2018/2020 recommendations, according to the risk group.Of the 2,049 localized CaPs included in our study, 591 belonged to the low-risk group, 1059 to the intermediate-risk group, and 399 to the high-risk group. In the low-risk group 45.2% of the cases did not follow the CCAFU 2016/2018, 2018/2020 recommendations in the imaging workup, 77.3% in the intermediate-risk group and 80.9% in the high-risk group. For our entire study, 1,408 patients (68.7%) had an imaging workup that did not follow the CCAFU recommendations.Our results show a low adhesion of urologists to the CCAFU recommendations in the imaging assessment of localized CaP. The causes of this non-adhesion are multifactorial and difficult to analyze.

Resume Objectif L’objectif de cette etude est de presenter l’evolution de l’epidemiologie du cancer du rein dans l’Herault a partir des donnees collectees par le registre des tumeurs de l’Herault (RTH) sur une periode de 30 ans. Materiels et methodes A partir de la base de donnees du RTH, nous avons etudie l’evolution du cancer du rein de 1987 a 2016. Nous avons analyse les donnees concernant l’incidence, la mortalite, l’anatomopathologie des tumeurs et leur stade au diagnostic. Nous avons compare ces resultats aux donnees nationales et internationales. Resultats Nous avons recense 3769 nouveaux cas de cancers du rein: 2628 chez l’homme (69,7 %) et 1141 chez la femme (30,3 %). En 2016, le cancer du rein etait le 8e cancer tous sexes confondus, le 7e cancer chez l’homme et le 11e chez la femme. Entre 1987 et 2016 le nombre de nouveaux cas de cancer du rein a ete multiplie par 4,2 chez l’homme et par 3,3 chez la femme. Le nombre de formes localisees a augmente de 9 % en 20 ans. En 2016 la probabilite, d’etre atteint d’un cancer du rein avant 75 ans est de 2,11 % pour un homme et de 0,62 % pour une femme. Conclusion En 30 ans, l’incidence du cancer du rein a fortement augmente dans l’Herault alors que l’on observe une diminution de sa mortalite. Ces donnees analytiques seront ameliorees par le developpement du Registre de l’Herault Specialise en Onco Urologie (RHESOU) Niveau de preuve 3.

Objectifs Le registre des tumeurs de l’Herault (RTH) est un registre general qualifie par le comite national des registres depuis 1987. L’objectif de cette etude est de presenter l’evolution de l’epidemiologie du cancer de la vessie dans le departement de l’Herault a partir des donnees collectees par le RTH sur une periode de 30 ans. Methodes A partir de la base de donnees du RTH, nous avons etudie l’incidence, les taux d’incidence standardises sur la population mondiale (TSM), la frequence relative, le sex-ratio, l’âge moyen au diagnostic, les donnees anatomopathologiques et les primo-traitements pour toutes les tumeurs de la vessie ≥ T1 dans la population de l’Herault entre 1987 et 2016. Les donnees de mortalite proviennent du service SC8 de l’INSERM (CepiDC). Nous avons compare ces resultats aux donnees nationales et internationales. Les estimations francaises proviennent des donnees FRANCIM et les donnees mondiales des registres sont regroupees par le Centre international de recherche sur le cancer (CIRC), situe a Lyon. Resultats Les TSM du cancer de la vessie pour 100 000 sont passes de 11,1 en 1987–1988 (21 hommes, 3,1 femmes) a 8,2 en 2015–2016 (15,2 hommes, 2,5 femmes). Sur 30 ans, le RTH a recense 5580 cas et 2718 deces. Le rapport mortalite/incidence etait de 48,7 % (45,9 % chez l’homme, 62,1 % chez la femme) et le sex-ratio etait de 4,7 hommes pour une femme. En 2016, il etait le 7e cancer dans l’Herault (5e chez l’homme). Les carcinomes urotheliaux representaient 91,7 % des cancers. En 2016, l’âge moyen au diagnostic etait de 74,8 ans (74,2 ans chez l’homme, 76,9 ans chez la femme) et la probabilite d’avoir un cancer de la vessie avant l’âge de 75 ans etait de 1,81 % pour un homme (1/55) et 0,26 % pour une femme (1/382) ( Fig. 1 ). Discussion L’incidence des tumeurs de la vessie a faiblement diminue chez l’homme dans l’Herault. Les registres ne recueillent que les tumeurs ≥ T1, ce qui differe des recommandations cliniques. En 2018, le Registre de l’Herault Specialise en Onco-Urologie (RHESOU) a vu le jour, dans le but d’apporter plus de coherence entre les donnees epidemiologiques et la pratique clinique actuelle. Conclusion L’incidence des tumeurs de la vessie a faiblement diminue chez l’homme dans l’Herault. Les registres ne recueillent que les tumeurs ≥ T1, ce qui differe des recommandations cliniques. En 2018, le Registre de l’Herault Specialise en Onco-Urologie (RHESOU) a vu le jour, dans le but d’apporter plus de coherence entre les donnees epidemiologiques et la pratique clinique actuelle.

The objective of this study is to present the history of cancers of the external genital organs of male in Hérault using data from the Hérault tumor register (RTH) over a period of 30 years.Using the RTH database, we studied the development of testicular germ cell tumors (TGCT) and penile cancer (PC) over 30 years, from 1987 to 2016. We analyzed the incidence and mortality data for these tumors. We compared these results to French, European and global data.In 30 years of registration we have recorded 725 cases of TGCT and 175 cases of PC. The age standardized incidence rate (ASR) of TGCT has doubled between 1987 and 2016 (4.2 per 100,000 in 1987 and 9.3 per 100,000 in 2016). It was multiplied by 2.63 in the population of patients aged 30 to 44. There is a decrease of the mortality rate with a ASR of 0.8 deaths per 100,000 in 1987, and 0.4/100 000 in 2016. The PC incidence ASR was stable between 1987 and 2016 (0.4-0.9/100,000). Mortality is stable with a ASR between 0.1 and 0.3 deaths per 100,000 between 1987 and 2016.The incidence of TGCT has increased sharply in the Hérault over the past 30 years, while a decrease in mortality has been observed. The proportion of seminomas is increasing; it has gone from 53 % to 60 % in 30 years in the Hérault. The incidence and mortality of PC shows a stability in the Hérault over the past 30 years.

The objective of the study was to determine the specificities of renal cell carcinoma (RCC) in the department of Herault using the Herault Tumor Registry over 30 years.Data of this study were obtained from the Herault cancer database. We analysed the evolution of RCC from 1987 to 2016, including the incidence, mortality, cancer pathology and staging at the moment of diagnosis. We compared our results with national and international data.We identified 3769 newly diagnosed RCC: 2628 in men (69,7%) and 1141 in women (30,3%). In 2016, RCC was the 8th most frequent cancer, both genders combined, the 7th most frequent cancer in men and the 11th in women. New cases of RCC increased by 4.2 in men and 3.3 in women over the study period. The number of localised forms increased by 9% over 20 years. In 2016, the probability of having a RCC before the age of 75 was of 2.11% for a man and of 0.62% for a woman.Over 30 years, the incidence rate of RCC increased in the department of Herault; however, mortality decreased over the same period. This analytical data should be improved by the development of the Registry of Herault Specialised in Onco-Urology (RHESOU).3.

Overall treatment time is an important factor of local recurrence and indirectly of distant evolution, namely in case of protracted treatments. The current pandemic impacts on the duration of radiotherapy if patients under treatments and synchronously suffering from COVID-19. The models used to compensate the total dose in case of temporary treatment interruption are well known but it is of importance in that pandemic context to update and homogenize clinical practice in order to improve local control without increasing normal tissue complications.

Liver stereotactic body radiotherapy is a developing technique for the treatment of primary tumours and metastases. Its implementation is complex because of the particularities of the treated organ and the comorbidities of the patients. However, this technique is a treatment opportunity for patients otherwise in therapeutic impasse. The scientific evidence of liver stereotactic body radiotherapy has been considered by the French health authority as insufficient for its widespread use outside specialized and experienced centers, despite a growing and important number of retrospective and prospective studies, but few comparative data. This article focuses on the specific features of stereotactic body radiotherapy for liver treatments and the results of published studies of liver stereotactic body radiotherapy performed with classic linear accelerators and dedicated radiosurgery units., La radiothérapie stéréotaxique hépatique est une technique de traitement en développement pour le traitement des tumeurs primitives et secondaires. Sa mise en œuvre est complexe du fait des particularités de l’organe traité et des comorbidités des patients. Elle représente cependant une opportunité de traitement efficace pour beaucoup de patients en impasse thérapeutique. Son niveau de preuve est jugé insuffisant par la Haute Autorité de Santé (HAS) pour une large diffusion en dehors des centres expérimentés. Il existe pourtant un nombre conséquent et grandissant d’études rétrospectives ou prospectives, mais peu de données comparatives. Cet article résume les particularités de la radiothérapie stéréotaxique pour cette localisation et reprend les résultats des études publiées pour les machines dédiées et non dédiées.

We propose in this short review to report the impact of stereotactic body radiation therapy (SBRT) in oligometastatic or oligoprogressive cancer patients in terms of metastatic progression-free and global survival, and to identify the place of SBRT in patient's pathway.

The impact of curative radiotherapy depends mainly on the total dose delivered homogenously in the target volume. Tumor sensitivity to radiotherapy may be particularly inconstant depending on location, histology, somatic genetic parameters and the capacity of the immune system to infiltrate the tumor. In addition, the dose delivered to the surrounding healthy tissues may reduce the therapeutic ratio of many radiation treatments. In a same population treated in one center with the same technique, it appears that individual radiosensitivity clearly exists, namely in terms of late side effects that are in principle non-reversible. This review details the different radiobiological approaches that have been developed to better predict the tumor response but also the radiation-induced late effects.

Randomized trials demonstrated similar overall survival between mastectomy and breast-conservative surgery followed by adjuvant radiation therapy. Breast-conservative surgery, with adjuvant radiation therapy, with or without neoadjuvant systemic therapy has become the standard of care for women with early or locally advanced breast cancer. Nevertheless, certain cardiac, lung or cutaneous toxicities may alter the long-term body image and the quality of life of a limited number of patients who consider having had "overtreatment" or treatment outside the best knowledge of science. In case of low-risk breast cancer, several trials have evaluated the carcinologic outcome in absence of radiation therapy after breast-conservative surgery. Local recurrences increased in case of breast-conservative surgery alone but without impact on overall survival. Multiple debates have emerged in order to select the most appropriate evaluation criteria. Finally, a large consensus has considered that reducing local recurrences is important but with modern technologies and after identifying patients of individual radiosensitivity. Indeed, in case of a low absolute risk of local recurrence, radiation therapy techniques have been developed to allow a focal treatment especially for patients with high risk of developing late effects. This kind of compromise takes into account the reduction risk of local recurrences but also the probability of developing radiation-induced cutaneous sequelae. In the same way, for patients considered at high risk of recurrence, the huge volumes need specific techniques to better cover the targets while protecting the surrounding critic organs such as heart and lung. Intensity-modulated radiation therapy and the local high boost may help to decrease local recurrences of these more extended and aggressive diseases while considering the individual radiosensitivity that paves the way of long-term sequelae. In this article, we detail a personalized approach of breast radiation therapy considering the absolute risk of local recurrences and the probability of radiation-induced toxicity appearance.

Prostate cancer is a sensitive adenocarcinoma, in more than 80% of cases, to chemical castration, due to its hormone dependence. Locally advanced and/or high-risk cancer is defined based on clinical stage, initial prostate specific antigen serum concentration value or high Gleason score. Hormone therapy associated with radiation therapy is the standard of management and improves local control, reduces the risk of distant metastasis and improves specific and overall survival. Duration of hormone therapy, dose level of radiation therapy alone or associated with brachytherapy are controversial data in the literature. The therapeutic choice, multidisciplinary, depends on the age and comorbidity of the patient, the prognostic criteria of the pathology and the urinary function of the patient. Current research focuses on optimizing local and distant control of these aggressive forms and incorporates neoadjuvant or adjuvant chemotherapy and also new hormone therapies.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.007. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.007. That newer version of the text should be used when citing the article.

Thanks to the improvement in radiotherapy physics, biology, computing and imaging, patients presenting with liver tumors can be efficiently treated by radiation. Radiotherapy has been included in liver tumors treatment guidelines at all disease stages. Liver stereotactic radiotherapy has to be preferred to standard fractionated radiotherapy whenever possible, as potentially more efficient because of higher biological equivalent dose. Liver stereotactic radiotherapy planning and delivery require extensive experience and optimal treatment quality at every step, thus limiting its availability to specialized centres. Multicentre studies are difficult to develop due to a large technical heterogeneity. Respiratory management, image guidance and immobilization are considerations as important as machine type. The use of multimodal planning imaging is compulsory to achieve expected contouring quality. Treatment efficacy is difficult to assess following liver stereotactic radiotherapy, but local control is high and toxicity unusual. As a consequence, liver stereotactic radiotherapy is part of multimodal and multidisciplinary management of liver tumors.

The purpose of the guidelines national committee CCAFU was to propose updated french guidelines for localized and metastatic prostate cancer (PCa).A Medline search was achieved between 2013 and 2016, as regards diagnosis, options of treatment and follow-up of PCa, to evaluate different references with levels of evidence.Epidemiology, classification, staging systems, diagnostic evaluation are reported. Disease management options are detailed. Recommandations are reported according to the different clinical situations. Active surveillance is a major option in low risk PCa. Radical prostatectomy remains a standard of care of localized PCa. The three-dimensional conformal radiotherapy is the technical standard. A dose of74Gy is recommended. Moderate hypofractionation provides short-term biochemical control comparable to conventional fractionation. In case of intermediate risk PCa, radiotherapy can be combined with short-term androgen deprivation therapy (ADT). In case of high risk disease, long-term ADT remains the standard of care. ADT is the backbone therapy of metastatic disease. In men with metastases at first presentation, upfront chemotherapy combined with ADT should be considered as a new standard. In case of metastatic castration-resistant PCa (mCRPC), new hormonal treatments and chemotherapy provide a better control of tumor progression and increase survival.These updated french guidelines will contribute to increase the level of urological care for the diagnosis and treatment for prostate cancer. © 2016 Elsevier Masson SAS. All rights reserved.

Resume Objectif Le but du Comite de cancerologie de lʼAssociation francaise dʼurologie etait de proposer une mise a jour des recommandations dans la prise en charge du cancer de la prostate (CaP). Methodes Une revue systematique (Medline) de la litterature de 2013 a 2016 a ete conduite par le CCAFU concernant les elements du diagnostic, les options de traitement et la surveillance du CaP, en evaluant les references avec leur niveau de preuve. Resultats Les recommandations precisent la genetique, lʼepidemiologie et les moyens diagnostiques du CaP. Lʼimagerie par resonance magnetique (IRM) est lʼexamen dʼimagerie de reference du cancer localise. Le score de Gleason a ete redefini par lʼInternational Society of Urological Pathology (ISUP) en cinq groupes pronostiques. Les moyens therapeutiques ont ete detailles, puis recommandes en fonction des situations cliniques. La surveillance active (SA) est une option therapeutique de reference pour les tumeurs de faible risque evolutif. La chirurgie reste une solution therapeutique majeure du CaP localise. Elle doit etre envisagee dans un cadre multimodal pour les formes a haut risque. La radiotherapie doit utiliser une technique conformationnelle tridimensionnelle si possible en modulation dʼintensite a une dose > 76 Gy. Lʼhypofractionnement modere apporte un controle biochimique equivalent sans augmentation majeure de la toxicite. LʼHT courte peut etre associee a lʼirradiation pour les tumeurs de risque intermediaire « fort ». Pour les formes a haut risque, lʼassociation a une HT longue reste la reference. LʼHT est le traitement de fond au stade metastatique. La prevention des effets secondaires de lʼHT est fondamentale. Lʼhormonochimiotherapie de premiere ligne pour le traitement des CaP metastatiques hormono- et chimio-naifs est le traitement standard en cas de cancer dʼemblee metastatique chez les patients dont lʼetat de sante est compatible avec lʼusage de docetaxel. Chez les patients presentant un cancer de prostate resistant a la castration (CPRC), lʼapport des nouvelles therapies qui ont emerge ces dernieres annees aide a mieux controler la progression tumorale et a ameliorer la survie. Conclusions Cette actualisation des recommandations francaises doit contribuer a ameliorer la prise en charge des patients porteurs dʼun CaP. © 2016 Elsevier Masson SAS. Tous droits reserves.

International audience; OBJECTIVE:The purpose of the guidelines national committee CCAFU on bladder cancer was to propose updated french guidelines for non-muscle invasive (NMIBC) and invasive (MIBC) bladder cancers.METHODS:A Medline search was achieved between 2013 and 2016, as regards diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.RESULTS:Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumour. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment : instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on pelvic-abdominal and thoracic CT-scan; MRI and FDG-PET remain optional. Cystectomy associated with extensive pelvic lymph nodes resection is considered the gold standard for non metastatic MIBC. An orthotopic bladder substitution should be proposed to both male and female patients lacking any contraindications and in cases of negative frozen urethral samples. The interest of neoadjuvant chemotherapy is well known for all MIBC, wathever the stage. Thus, neoadjuvant chemotherapy is recommended for all eligible patients according PS (PS 60ml/mn). As regards metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC). In second line treatment, only chemotherapy using vinflunine has been validated to date, even if results of immunotherapy clinical trials are encouraging.CONCLUSION:These updated french guidelines will contribute to increase the level of urological care for the diagnosis and treatment for NMIBC and MIBC. © 2016 Elsevier Masson SAS. All rights reserved.

International audience; The standard treatment for extremity soft tissue sarcomas is based on the association of surgery and radiotherapy. This strategy allows local control improvement with the risk of increased toxicity. There is therefore a growing interest to identify those patients who will benefit from radiotherapy and those who will have the same local control with surgery alone. Furthermore, the development of toxicity has been correlated with the extension of the irradiated volume and the volume receiving high doses. Technological development as intensity modulated radiotherapy and image-guided radiotherapy allows limited irradiated volume improving the protection of the organs at risk leading to clinical benefit improvement. Moreover, efforts are being done to improve local control for the patients at high risk of local relapse. In this paper, we discuss all these mentioned aspects.

International audience; Surgery (radical cystectomy) is the standard treatment of muscle-invasive bladder cancer. Radiochemotherapy has risen as an alternative treatment option to surgery as part as organ-sparing combined modality treatment or for patients unfit for surgery. Radiochemotherapy achieves 5-year bladder intact survival of 40 to 65% and 5-year overall survival of 40 to 50% with excellent quality of life. This article introduces the French recommendations for radiotherapy of bladder cancer: indications, exams, technique, dosimetry, delivery and image guidance.

In breast cancer, radiotherapy is an essential component of the treatment. After conservative surgery for an infiltrating carcinoma, radiotherapy must be systematically performed, regardless of the characteristics of the disease, because it decreases the rate of local recurrence and by this way, specific mortality. Partial breast irradiation could not be proposed routinely but only in very selected and informed patients. For ductal carcinoma in situ, adjuvant radiotherapy must be also systematically performed after lumpectomy. After mastectomy, chest wall irradiation is required for pT3-T4 tumours and if there is an axillary nodal involvement, whatever the number of involved lymph nodes. After neo-adjuvant chemotherapy and mastectomy, in case of pN0 disease, chest wall irradiation is recommended if there is a clinically or radiologically T3-T4 or node positive disease before chemotherapy. Axillary irradiation is recommended only if there is no axillary surgical dissection and a positive sentinel lymph node. Supra and infra-clavicular irradiation is advised in case of positive axillary nodes. Internal mammary irradiation must be discussed case by case, according to the benefit/risk ratio (cardiac toxicity). Dose to the chest wall or the breast must be between 45-50Gy with a conventional fractionation. A boost dose over the tumour bed is required if the patient is younger than 60 years old. Hypofractionation (42.5 Gy in 16 fractions, or 41.6 Gy en 13 or 40 Gy en 15) is possible after tumorectomy and if a nodal irradiation is not mandatory. Delineation of the breast, the chest wall and the nodal areas are based on clinical and radiological evaluations. 3D-conformal irradiation is the recommended technique, intensity-modulated radiotherapy must be proposed only in case of specific clinical situations. Respiratory gating could be useful to decrease the cardiac dose. Concomitant administration of chemotherapy in unadvised, but hormonal treatment could be start with radiotherapy.

Surgery (radical cystectomy) is the standard treatment of muscle-invasive bladder cancer. Radiochemotherapy has risen as an alternative treatment option to surgery as part as organ-sparing combined modality treatment or for patients unfit for surgery. Radiochemotherapy achieves 5-year bladder intact survival of 40 to 65% and 5-year overall survival of 40 to 50% with excellent quality of life. This article introduces the French recommendations for radiotherapy of bladder cancer: indications, exams, technique, dosimetry, delivery and image guidance.

Irradiation techniques for breast cancer (arctherapy, tomotherapy) are evolving and intensity-modulated radiation therapy is being increasingly considered for the management of these tumours. Here, we propose a review of intensity-modulated radiation therapy planning issues, clinical toxicities and indications for breast cancer.

Resume But Decrire les pratiques courantes de prescription du G-CSF en France en cancerologie mammaire, par rapport aux recommandations de l’EORTC en vigueur. Methodes Etude prospective observationnelle conduite entre fevrier 2008 et septembre 2009 evaluant la prescription d’un traitement par G-CSF instaure en prophylaxie primaire (PP) ou secondaire chez 869 patientes traitees par chimiotherapie (quelle que soit la ligne) pour un cancer du sein. Resultats L’âge moyen etait de 55 ans. Au total, 80,3 % des patientes etaient traitees en situation neoadjuvante/adjuvante (SANA), 78,9 % des prescriptions de G-CSF etaient en PP en SANA et 67,5 % en situation metastatique. Parmi les 702 patientes evaluables, les taux de neutropenies severe (NS) et febrile (NF) etaient respectivement de 9,3 % et 4,2 % lors d’une PP contre respectivement 12,4 % et 7,3 % en cas de non-prescription de G-CSF au premier cycle. La prescription de la PP etait principalement dictee par le type de chimiotherapie en SANA et par les facteurs de risque lies a la patiente ou a la maladie en situation localement avancee/metastatique. Conclusion L’etude montre que la prescription de G-CSF en pratique courante est conforme aux recommandations 2010 de l’EORTC avec cependant une tendance a une prescription plus large du G-CSF en pratique reelle.

International audience; Palliative radiation therapy is well-known in the setting of metastatic lesions (haemostatic, analgesic, anti-inflammatory aims, etc.). Palliative primary tumour radiotherapy is less studied. Here we propose a review of palliative indications of primary tumours, the most studied in the literature, and their radiotherapy modalities (target volumes and fractionation).; La prise en charge palliative en radiothérapie est largement connue comme traitement métastatique à visée symptomatique (hémostatique, antalgique, anti-inflammatoire, etc.). Elle est moins étudiée dans le cadre de la prise en charge de tumeur primitive localement évoluée qui requiert un traitement palliatif. Nous proposons de détailler dans cette revue les différentes indications, les volumes d’irradiation et les fractionnements adaptés concernant les types de tumeur primitive les plus décrits dans la littérature.

International audience; Irradiation of node areas is still a complex challenge in external radiotherapy for breast cancer. Acceptable target coverage is always balanced by protection of organs at risk and patient morphology. Intensity-modulated radiotherapy increases the quality of dose distribution on the planning target volume, but modifies dramatically the irradiation coverage of critical structures in a different way compared to 3D treatment. In this paper we analyze this new technique in breast treatment with node regions, its expected gain and potential risks.; L’irradiation des aires ganglionnaires de drainage du sein reste complexe dans le cadre d’une classique radiothérapie conformationnelle tridimensionnelle. La bonne couverture des volumes cibles est souvent compromise par la morphologie de la patiente et la protection des organes à risque. La radiothérapie conformationelle avec modulation d’intensité permet d’améliorer cette couverture mais modifie la distribution de la dose délivrée aux organes à risque par rapport à celle connue avec les techniques passées. Nous rapportons ici l’analyse de cette nouvelle technique, de son gain probable et de ses risques potentiels.

Introduction En oncologie, la qualite de vie relative a la sante (QdV) est devenue un critere essentiel dans les essais cliniques mais son analyse longitudinale reste complexe et non standardisee. Un des freins conceptuels de ce critere est son aspect multidimensionnel. En effet, la QdV comprend au minimum les fonctions physique, psychologique et sociale et les symptomes lies a la maladie ou au traitement. Actuellement, l’analyse longitudinale des donnees de QdV est realisee par dimension sur l’etude des scores via des modeles lineaires mixtes. Nous proposons dans ce travail une approche qui permet de tenir compte conjointement de l’aspect longitudinal et de la nature multidimensionnelle de la QdV. Methodes Les donnees observees sont issues d’auto-questionnaires collectes a differentes visites du traitement et du suivi. Le questionnaire standard en Europe est le QLQ-C30 developpe par l’EORTC. Il decompose la QdV en 15 dimensions : cinq dimensions fonctionnelles, neuf symptomatiques et le statut global de sante (« Global Health Status », GHS). A chaque temps, on construit un modele a equations structurelles (« Structural Equation Modeling », SEM) ou le GHS (unidimensionnel) est explique par deux variables latentes, chacune d’elles etant un facteur resumant respectivement les dimensions fonctionnelles, d’une part, et les dimensions symptomatiques, d’autre part. Pour tenir compte de l’aspect longitudinal, la variable GHS et les deux facteurs seront concatenes sur l’ensemble des visites. Nous pouvons ainsi par un modele mixte expliquer la GHS par les deux variables latentes globales. Ce modele prendra en compte l’effet individu (par un effet aleatoire) et un effet traitement. Ceci est rendu possible par la maximisation de la vraisemblance de chaque SEM utilisant l’algorithme EM. Cette approche, contrairement aux methodes classiques dans la litterature, donne une estimation des facteurs ce qui permet de les reintroduire dans un autre modele (ici le modele lineaire mixte). Cette technique d’estimation est de plus computationnellement efficace. Resultats Nous nous placons dans le cas d’une etude exploratoire ou nous voulons comparer la QdV globale entre deux bras de traitement. Nous illustrerons cette methode developpee sous le logiciel R par l’intermediaire de donnees issues de l’etude CO-HO-RT. Cet essai clinique de phase II randomise est mene sur 150 patientes menopausees traitees pour un cancer du sein en situation adjuvante avec des recepteurs hormonaux positifs. Il evalue les sequences de traitement de radiotherapie (concomitante ou sequentielle) associee a une hormonotherapie. La mesure de la QdV est realisee par les questionnaires EORTC-QLQ-C30 et EORTC-QLQ-BR23. Ce dernier est un module complementaire developpe specifiquement pour le cancer du sein. Il permet la consideration supplementaire de quatre dimensions fonctionnelles et symptomatiques, specifiques a la pathologie etudiee. Conclusions Cette approche est proposee pour eviter la multiplicite des tests induite par l’analyse independante de chaque dimension. Le modele propose pour analyser la QdV globale a partir des dimensions sous-jacentes, est intuitif : il decoule de la conception du questionnaire QLQ-C30. La methodologie utilisee a l’avantage d’estimer les facteurs pour chacun des individus ce qui rend possible l’analyse longitudinale.

IC2015, Session 1 : Méthodes et outils d’acquisition des connaissances, Rennes. EPI-CLIN 2015; National audience; IntroductionDe nos jours, les forums de santé sont de plus en plus utilisés par les patients, notamment lorsqu’ils souffrent de maladies chroniques. En maintenant l’anonymat, ces forums leur permettent de discuter librement avec d’autres patients et parfois avec des professionnels de santé de leurs résultats médicaux, de leurs options de traitement mais également de recevoir un soutien moral. Dans des travaux précédents, nous nous sommes intéressés à l’étude de la qualité de vie des patientes atteintes d’un cancer du sein à partir des forums de santé. Nous avons cherché à capturer et à quantifier ce que les patientes expriment dans les forums afin de comparer les thèmes directement issus de leurs préoccupations à ceux étudiés dans les autoquestionnaires EORTC-QLQC30 et EORTC-BR23. Une importante limitation à ces travaux vient du type de textes traités. En effet, la plupart des patients sont des profanes dans le domaine médical. Lors de leurs échanges, ils utilisent de l’argot, des abréviations et un vocabulaire spécifique construit par la communauté en ligne à la place des termes médicaux que l’on retrouve dans les ressources terminologiques utilisées par les professionnels de santé (ex. MeSH, UMLS, SNOMED, CISMeF). Or, ces terminologies de référence sont centrales à l’application des méthodes d’extraction de connaissances. Notre objectif dans ce travail est de construire une ressource lexicale qui aligne le vocabulaire des patients à celui des professionnels de santé. Ce type de ressource sera utilisé pour améliorer la recherche d’information dans les forums (ex. expansion de requêtes basées sur le vocabulaire des patients) et faciliter à terme l’élaboration d’études statistiques basées sur les informations extraites de ces forums. D’autres utilisations peuvent être envisagées comme l’écriture des brochures à destination des patients qui intègrent des éléments de ce vocabulaire.MéthodesDans un premier temps, nous avons récolté des messages à partir de forums recommandés aux patientes par la Ligue contre le cancer « www.cancerdusein.org », l’INCa « www.lesimpatientes.com » et de groupes Facebook d’échanges sur le cancer du sein. Ensuite, nous avons construit une ressource selon la chaîne de traitement suivante :– extraction des termes candidats basée sur des mesures fréquentielles ;– appariement des termes candidats patient/médecin sémantiquement similaire en utilisant une adaptation de la mesure de Levenshtein pour capturer les fautes d’orthographe fréquentes, l’inclusion pour les abréviations et l’alignement basé sur Wikipédia pour retrouver les termes co-occurrents.RésultatsQuelques exemples d’associations détectées sur les données du site « www.cancerdusein.org » sont : correction orthographique : cirose - cirrhose, abcé - abcès ; inclusion : chimio - chimiothérapie, onco - oncologue ; termes co-occurrents : crabe - cancer, bouton - acné. Pour valider nos résultats, nous allons procéder, d’une part, à une validation automatique partielle en utilisant une ressource lexicale appariant des termes utilisés par le grand public, donc non spécialisé en santé, et d’autre part, à une validation manuelle qui sera faite par des oncologues spécialistes du cancer du sein.ConclusionNous avons proposé une approche permettant de relier les termes utilisés par les patients aux termes utilisés par les professionnels de santé. Cette ressource est une brique essentielle pour exploiter automatiquement le contenu des forums de santé.

Brain metastases management has evolved over the last fifteen years and may use varying strategies, including more or less aggressive treatments, sometimes combined, leading to an improvement in patient's survival and quality of life. The therapeutic decision is subject to a multidisciplinary analysis, taking into account established prognostic factors including patient's general condition, extracerebral disease status and clinical and radiological presentation of lesions. In this article, we propose a management strategy based on the state of current knowledge and available therapeutic resources.

The sub Comittee prostate of the CCAFU established guidelines for diagnostic, treatment, evaluation and standart of care of prostate cancer.Guidelines 2010 were updated based on systematic literature search performed by the sub-Comittee in Medline and PubMed databases to evaluate references, levels of evidence and grade of recommandation.Pathological examination of the tissue specimens was defined specifically for Gleason score according to ISP 2005 recommandations. Prostate and pelvis RMN became the reference in terms of radiological exam. Individual and early diagnosis of prostate cancer was defined and role of PSA was precised. Active surveillance became one of the standart of care of low-risk tumors, radical prostatectomy remained one of the options for all risk group tumors, length of hormonotherapy in association with radiotherapy was precised according to the risk group. Side effects of hormonotherapy treament needed specific supervision ; hormonotherapy had no indication in case of non metastatic tumors and intermittent hormonotherapy in metastatic tumors. New hormonal drugs in pre and post chemotherapy and bone target drugs opened new therapeutics pathways.From 2010 to 2013, standarts of care of prostate cancer were modified because of results of prospective studies and new therapeutics. They allowed precise treatments for each specific clinical situation. In the future, multidisciplinary treatments for high risk tumors, time of adjuvant treatment and sequencies of new hormonal treatment had to be defined.

Resume Le succes de la radiotherapie depend principalement de la dose totale, delivree de maniere homogene dans la tumeur. Toutefois, la delivrance de cette dose est limitee par la tolerance des tissus sains dans le volume irradie. Dans une meme population traitee de maniere homogene sur le plan technique et evaluee par la meme equipe, il est clair qu’il existe une radiosensibilite intrinseque differente des tissus sains, notamment en termes de toxicite tardive, le plus souvent irreversible. Cette revue detaille les differentes avancees en radiobiologie clinique sur les effets secondaires tardifs apres radiotherapie et sur le developpement d’un test predictif de radiosensibilite des tissus sains avec sa possible utilisation en pratique clinique.

The impact of curative radiotherapy depends mainly on the total dose delivered homogenously in the targeted volume. Nevertheless, the dose delivered to the surrounding healthy tissues may reduce the therapeutic ratio of many radiation treatments. In a same population treated in one center with the same technique, it appears that individual radiosensitivity clearly exists, namely in terms of late side effects that are in principle non-reversible. This review details the different radiobiological approaches that have been developed to better understand the mechanisms of radiation-induced late effects. We also present the possibilities of clinical use of predictive assays in the close future.

In the era of high-tech radiotherapy, hypofractionated schema is more and more widely used regardless of tumour sites. In this article, we expose the role, techniques and indications of hypofractionated radiotherapy in adjuvant breast radiotherapy.

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.

The success of radiotherapy mainly depends on the total administered dose. This dose must be homogenously delivered onto the tumor and must preserve the surrounding healthy tissue. However, several patients are hypersensitive to ionizing radiations and may develop important radiation-induced early and late side effects. The prediction of these side effects remains currently impossible, involving to limit the given dose with the risk to decrease the therapeutic benefit for patients. Therefore, one of the major challenges in radiobiology is to accurately predict tumour radioresistance and to determine normal tissue radiosensitivity to tailor treatment. Several studies have been carried out and different predictive assays have been described in this field. However, none of them showed significant results for clinical use. For several years, many technological advances in proteomic fields have been performed in order to identify new biomarkers. After a brief description of the main characteristics of tumor radioresistance and normal tissue radiosensitivity, we will develop in this review the different approaches proposed so far to identify predictive tools of radiotherapy outcome. We will then analyze in detail how proteomic studies can improve the understanding of mechanisms associated with radiosensitivity of healthy tissue and radioresistance of tumor cells and how they could highlight new predictive biomarkers in radiobiology.

Intensity modulated radiotherapy (IMRT) is a technique allowing dose escalation and normal tissue sparing for various cancer types. For breast cancer, the main goals when using IMRT were to improve dose homogeneity within the breast and to enhance coverage of complex target volumes. Nonetheless, better heart and lung protections are achievable with IMRT as compared to standard irradiation for difficult cases. Three prospective randomized controlled trials of IMRT versus standard treatment showed that a better breast homogeneity can translate into better overall cosmetic results. Dosimetric and clinical studies seem to indicate a benefit of IMRT for lymph nodes irradiation, bilateral treatment, left breast and chest wall radiotherapy, or accelerated partial breast irradiation. The multiple technical IMRT solutions available tend to indicate a widespread use for breast irradiation. Nevertheless, indications for breast IMRT should be personalized and selected according to the expected benefit for each individual.

Technology development in radiotherapy has improved significantly during the last decade. The rapid evolution of 3D radiotherapy to intensity-modulated radiotherapy was possible thanks to inverse planning systems. Intensity modulated radiotherapy improved in its turn by possibilities of volumetric irradiation during a single rotation, reducing therefore the overall treatment. This article presents the technical parameters of this volumetric irradiation technique and a review of miscellaneous clinical indications.

Many clinical studies have showed the key role of radiotherapy in anticancer treatment strategy. Radiations are delivered alone or in combination with systemic therapies. In recent years, the main goal of all clinical developments has focused on improving clinical benefit, with an increased tumour control and a higher normal tissue protection. This research was designed to reduce local recurrences, to increase recurrence-free or overall survival and to decrease acute and late effects. Technological and biological evolutions (or revolutions) accompanied clinicians to improve clinical benefit, namely with strong progress in radiology and better understanding of radiobiology, particularly at the molecular level. Differences in tumour and normal tissues radiosensitivity are nowadays integrated in daily clinical practice of radiation oncologists. The current report details the last 5-year developments of clinical and translational research in radiation oncology, especially the role of French teams in the development of personalized treatment.

During the last French radiation oncology society annual congress, the therapeutic options for the management of brain metastases were presented. The indications and limits of surgery, stereotactic radiotherapy and whole brain radiotherapy, as well as their benefit in terms of overall survival, local control and improvement of the functional and neurocognitive status were discussed. The prognosis significance of the different phenotypes of breast cancer on the risk for BM as well as their roles in the treatment of brain metastases were also described. Surgery improves overall survival for patients with a single brain metastase and should be considered in the case of symptomatic lesions. The overall survival of patients treated with stereotactic radiotherapy do not differ from that of patients treated with surgery. These treatments should be mainly considered for patients with good performance status, one to three small brain metastases (3cm) and limited extracranial disease. Whole brain radiotherapy is more and more discussed in adjuvant setting due to potential late neurocognitive toxicity. This toxicity could be improved with the development of techniques sparing the hippocampus. HER2+ and triple-negative breast cancer patients are at increased risk for brain metastases. Prognosis of these patients differs as the overall survival of HER2+ patients has improved with anti-HER2 therapies. The optimal combination of local and systemic therapies remain to be determined.

Adenoid cystic carcinoma represents 1% of head and neck cancers. Adenoid cystic carcinomas are slow growing tumours with high potential for local recurrence. Treatment usually associates radiotherapy and surgery, but the role of radiotherapy remains unclear. We report a retrospective multicentric study of the management and prognostic factors of 169 adenoid cystic carcinomas of head and neck.Between 1982 and 2010, 169 patients with adenoid cystic carcinoma of the head and neck were referred to the Cercle des oncologues radiothérapeutes du Sud departments of radiotherapy either for primary untreated tumour (n=135) or for a recurrence of previously treated tumour (n=34). The site of adenoid cystic carcinoma was: parotid gland (n=48, 28.4%), minor salivary gland (n=35, 20.7%), submandibular gland (n=22, 13%), sinus cavities (n=22, 13%), other (n=42, 24.9%). Tumour stages were: T1 (12.4%); T2 (14.2%); T3 (12.4%); T4 (41.4%) and Tx (19.5%). Lymph node involvement was 13% and distant metastasis 8.9%. For adenoid cystic carcinomas of the parotid gland, major nerve involvement was evaluated. Preferential site of metastasis was the lung (87.5%). Treatments were: surgery alone (n=27), surgery and adjuvant radiotherapy (n=89), surgery and adjuvant chemoradiotherapy (n=12), exclusive chemoradiotherapy (n=13), exclusive radiotherapy (n=14), other associations (n=5) and no treatment (n=7). Radiotherapy was delivered through photons (n=119), neutrons (n=6), both (n=4). Two patients had a brachytherapy boost. Median prescribed doses to T and N were respectively 65 Gy and 50 Gy for the 119 photons treated patients.Mean follow-up was 58 months (range 1-250 months). As of December 1, 2010, 83 patients were alive with no evolutive disease (49%), 35 alive and had recurred, 18 had uncontrolled evolutive disease, 28 had died of adenoid cystic carcinoma and 5 of intercurrent disease. Overall survival and disease free survival were respectively 72% and 72% at 5 years, 53% and 32% at 10 years; 5 and 10-year freedom from local recurrence were 81% and 52% respectively. Nerve involvement was found in 17/48 parotid gland adenoid cystic carcinomas. The Cox model including all patients, showed that surgery (P0.001), surgical margins (P=0.015), nerve involvement (P=0.0079), length of radiotherapy (P=0.018), and tumour location (P=0.041) were associated with disease free survival.In this large series of adenoid cystic carcinoma of head and neck with a majority of T3-T4 tumours, 10-year survivals were achieved for 50% of patients. Radiotherapy did not impact survival.

The use of intraoperative radiation therapy in breast cancer patients started about 20 years ago. Several retrospective and prospective studies have been published. Intraoperative radiation therapy was initially given as a boost to the tumour bed, followed by whole-breast irradiation. These studies have demonstrated the feasibility of the technique, with local control rates and cosmetic results similar to those obtained with standard treatments. Accelerated partial breast irradiation yields local recurrence rates as low as those observed after whole-breast irradiation. Intraoperative radiation therapy as a single irradiation modality with a unique dose has been investigated in recent prospective studies showing satisfactory local results. Intraoperative radiation therapy can be proposed either as a boost or as a unique treatment in selected cases (tumour size, nodal and hormonal status, patient's age). Intraoperative radiation therapy can be delivered by orthovoltage (50 kV) X-rays from mobile generators, or by electrons from linear accelerators, mobile or fixed, dedicated or not to intraoperative radiation therapy.

Various subgroups of breast tumours have been identified during the last 10 years according to the risk of local relapse. Prognostic factors for local relapse are age, surgical margins, tumour size, Her2 expression and hormonal receptors status. For tumours with a high risk of local relapse, an increased in boost dose or the addition of new drugs (trastuzumab, antiangiogenics, PARP inhibitors) could be considered. For low risk tumours, hypofractionated, accelerated partial breast and intraoperative radiotherapy are being evaluated. The classical schedule (45-50 Gy to the whole gland followed by a boost dose of 16 Gy) is no longer the universal rule. Treatment individualization, according to clinical and biological characteristics of the tumour and - possibly - to the radiobiological profile of the patient, is likely to be the future of breast cancer radiotherapy.

During the annual congress of the SFRO, a symposium, on "Therapeutic innovations", described some of the burning questions in the treatment of prostate cancer. What is the best technique to perform radiation dose escalation, brachytherapy or Intensity modulated radiotherapy? Rational has been highlighted for both techniques, but without a prospective comparative trial, no definitive answer could be given today. The role of neo-adjuvant hormonal treatment, before surgery or radiotherapy is still discussed, particularly in the area of LH-RH antagonists which have a rapid and profound anti-hormonal effect. At least, the salvage treatment for biochemical relapse after external beam irradiation has been discussed: surgery, cryotherapy, and High-Intensity focalised ultrasons and the timing of hormonal treatment.

The oncologic outcome and the total dose are highly correlated with the treatment by ionizing radiation. The dose increase (total or per fraction) may provoke late-side effects that are potentially irreversible. The radiation-induced CD8 lymphocyte apoptotic value and the molecular modifications within the lymphocyte are capable of predicting the level of risk of developing late-side effects after curative intent radiotherapy. In this review, we present the different blood assays in this setting and discuss the current possibilities of researches, namely those involving the proteomic process.

Radiation therapy is now widely accepted as an efficacious treatment of localized prostate cancer. The technical developments of recent years have enabled the evolution of a three-dimensional conformal radiotherapy, offering a better adaptation of the dose distribution, and leading therefore to preserve organs at risk. In addition, the required dose delivered to the target volume permit physician to increase the total dose if necessary. This requires a thorough knowledge of the radio-anatomy of the prostate, the natural history of the disease but also the ballistics and dosimetry. The objectives of this work were to detail epidemiology and radio-anatomy of the prostate cancer. In addition, conformal radiation modalities are illustrated by a case report.

Positron emission tomography is a functional imaging technique that allows the detection of the regional metabolic rate, and is often coupled with other morphological imaging technique such as computed tomography. The rationale for its use is based on the clearly demonstrated fact that functional changes in tumor processes happen before morphological changes. Its introduction to the clinical practice added a new dimension in conventional imaging techniques. This review presents the current and proposed indications of the use of positron emission/computed tomography for prostate, bladder and testes, and the potential role of this exam in radiotherapy planning.

Intensity-modulated radiotherapy (IMRT) has highly impacted on the dose delivery thanks to inverse-planning dosimetry. Conformal isodoses to target volumes and critical organ protection have led to treatment possibilities which were unrealizable with conventional 3D technique. Nevertheless, time delivery using IMRT was in some cases longer than 3D radiotherapy. In order to compensate for this limitation, we have developed since 2007 a volumetric modulated arctherapy (RapidArc) in partnership with Varian. The technique, the results of the dosimetry plans, and quality control of the 142 first patients treated since November 2008 are presented in this review.

"Dose-painting" radiotherapy allows for a heterogeneous delivery of radiation within the tumour volume by targeting radioresistant areas defined by functional imaging. Within gross tumour volume, it is possible to define one or more target volumes based on biology (biological target volume [BTV]) and to apply a strategy of intensity modulated radiation therapy (IMRT) that will deliver a higher dose to these regions. In this review of the literature, we will highlight the biological elements responsible for radioresistance, and how to image them, then we will detail the radiotherapy techniques necessary for this approach, before presenting clinical results in various situations (head and neck tumours, prostate, brain tumours, etc.). Despite many difficulties that make dose-painting IMRT unusable in routine nowadays, biology-guided radiation therapy represents one of the major pathways of development of radiotherapy in the coming years.

The impact of curative radiotherapy depends mainly on the total dose delivered homogenously in the targeted volume. Nevertheless, the dose delivered to the surrounding healthy tissues may reduce the therapeutic ratio of many radiation treatments. Two different side effects (acute and late) can occur during and after radiotherapy. Of particular interest are the radiation-induced sequelae due to their irreversibility and the potential impact on daily quality of life. In a same population treated in one centre with the same technique, it appears that individual radiosensitivity clearly exists. In the hypothesis that genetic is involved in this area of research, lymphocytes seem to be the tissue of choice due to easy accessibility. Recently, low percentage of CD4 and CD8 lymphocyte apoptosis were shown to be correlated with high grade of sequelae. In addition, recent data suggest that patients with severe radiation-induced late side effects possess four or more single nucleotide polymorphisms (SNP) in candidate genes (ATM, SOD2, TGFB1, XRCC1, and XRCC3) and low radiation-induced CD8 lymphocyte apoptosis in vitro. On-going studies are being analyzing the entire genome using a Genome-wide association study (GWAS) analysis.

Pure testicular seminoma is a rare disease with an excellent prognosis. Its management is controversial. In stage I disease, several treatment options are considered. Those are radiation therapy alone, chemotherapy alone or active surveillance, which is becoming increasingly popular. For more advanced stages, treatment is based on chemotherapy with or without radiation therapy. In this article, we review thoroughly the existing literature and recent recommendations the various treatment options, their advantages and disadvantages in different stages of the disease.