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Purpose The aim of this study is to correlate locoregional relapse with radiation therapy volumes in patients with rectal cancer treated with neoadjuvant chemoradiation in the ACCORD 12/0405-PRODIGE 02 trial. Patients and methods We identified patients who had a locoregional relapse included in ACCORD 12's database. We studied their clinical, radiological, and dosimetric data to analyze the dose received by the area of relapse. Results 39 patients (6.5%) presented 54 locoregional relapses. Most of the relapses were in-field (n = 21, 39%) or marginal (n = 13, 24%) with only six out-of-field (11%), 14 could not be evaluated. Most of them happened in the anastomosis, the perirectal space, and the usual lymphatic drainage areas (presacral and posterior lateral lymph nodes). Only patients treated for a lower rectum adenocarcinoma had a relapse outside of the treated volume. 2 patients with T4 tumors extending into anterior pelvic organs had relapses in anterior lateral and external iliac lymph nodes. Conclusions Lowering the upper limit of the treatment field for low rectal tumors increased the risk of out of the field recurrence. For very low tumors, including the inguinal lymph nodes in the treated volume should be considered. Recording locoregional involvement, treated volumes, and relapse areas in future prospective trials would be of paramount interest to refine delineation guidelines.

Introduction: Adjuvant whole-pelvic radiation therapy (WPRT) improves locoregional control for high-intermediate stages I–III endometrial cancer patients. Intensity modulated radiation therapy (IMRT) tends to replace the standard 3D conformal radiation therapy (3DCRT) technique used in trials. Material and methods: Consecutive patients with stages I–IIIc endometrial cancer treated between 2008 and 2014 in our department with post-operative 3DCRT or IMRT WPRT were studied retrospectively. Patients with cervical involvement underwent additional low-dose rate vaginal brachytherapy. The impact of the WPRT technique on local control, tolerance, disease-free survival (DFS) and overall survival (OS) was assessed. Clinicians evaluated routinely acute radiation toxicity each week during radiation therapy and late toxicity during standard follow-up consultations. Results: Median follow-up was 50 months (range: 6–158). Among the 83 patients included, 47 were treated with 3DCRT and 36 with IMRT. There was no difference in patient characteristics between groups. The 5-year locoregional control and DFS rates were 94.5% and 68%, respectively. No significant difference was found between the 3DCRT and IMRT groups in terms of survival, with 5-year OS rates of 74.6% and 78%, respectively. In multivariate analysis, age over 68, stage > T1 and grade 3 were independently associated with shorter DFS and OS. Seven patients (8.4%) had grades 3–4 acute gastrointestinal (GI) toxicity with five patients (10.6%) and two (5.4%) in the 3DCRT and IMRT groups, respectively (p = .69). One case (1.2%) of late grade 3 GI toxicity was observed treated in 3DCRT. Conclusions: IMRT seems to be a safe technique for the treatment of endometrial cancer with a trend towards decreased acute GI toxicities. Results of the phase 3 RTOG 1203 trial are needed to confirm these results.

Currently, the use of radiation therapy for patients with pancreatic cancer is subject to discussion. In adjuvant setting, the standard treatment is 6 months of chemotherapy with gemcitabine and capecitabine. Chemoradiation (CRT) may improve the survival of patients with incompletely resected tumors (R1). This should be confirmed by a prospective trial. Neoadjuvant CRT is a promising treatment especially for patients with borderline resectable tumors. For patients with locally advanced tumors, there is no a standard. An induction chemotherapy followed by CRT for non-progressive patients reduces the rate of local relapse. Whereas in the first trials of CRT large fields were used, the treated volumes have been reduced to improve tolerance. Tumor movements induced by breathing should be taken in account. Intensity modulated radiation therapy allows a reduction of doses to the organs at risk. Whereas widely used, this technique is not recommended.

Introduction et but de l’etude L’essai Accord 12/0405-Prodige 02 a compare les protocoles CAP45 (capecitabine 45 Gy) et Capox50 (capecitabine-oxaliplatine 50 Gy) dans la prise en charge neoadjuvante des adenocarcinomes rectaux localement evolues. Cette etude s’est interessee aux rechutes locoregionales et a leur rapport avec la dose delivree. Materiel et methodes Grâce a Unicancer nous avons identifie les patients inclus dans l’essai Accord 12 ayant eu une rechute locoregionale. Nous avons ensuite etudie leurs donnees cliniques, radiologiques et de planification de traitement pour creer des donnees digital imaging and communications in medicine (Dicom) et evaluer la dose recue au niveau du site de rechute. Les rechutes ont ete classees en trois categories : – dans le volume traite (couvertes a 95 % par l’isodose 95 %), – marginales (couvertes entre 20 et 95 % par l’isodose 95 %), – hors du volume traite (couvertes a moins de 20 % par l’isodose 95 %). Resultats et analyse statistique Les sites de rechutes selon les caracteristiques tumorales sont presentes dans le Tableau 1 La majorite des rechutes etait dans le volume traite ou marginales (anastomose, espace perirectal et aires de drainage habituelles (presacrees et lateropelviennes posterieures). Seuls les patients recevant un traitement pour une tumeur du bas rectum ont ete atteints de rechutes hors du volume traite (notamment en inguinal). Des tumeurs de stade T4 envahissant les organes pelviens anterieurs ont rechute dans les aires ganglionnaires (obturatrices et iliaques externes). Conclusion Cette etude remet en question le fait d’abaisser la limite superieure du volume irradie en S2-S3, notamment pour les tumeurs du bas rectum. Elle fait se poser la question d’irradier pour les tumeurs du bas rectum les aires inguinales. Des donnees prospectives de qualite issues des prochains essais permettront de confirmer ces donnees.

Introduction The aim of this study was to compare dosimetric gain using dynamic conformal arc (DCA) with flattened filter (FF) and flattening filter free (FFF) beam for lung stereotactic body radiation therapy (SBRT). Methods and materials In our institution, SBRT lung cancer patients were treated with prescribed dose 60 Gy in 4 or 8 fractions. In Pinnacle 9.10 were planned two partial DCA’s for peripheral tumors and three to four partial DCA’s for central region tumors to help pull dose of the OARs (heart, esophagus, spinal cord and ribs). Treatments were delivered with 6 MV beams and dose rate 600 MU, for TrueBeam STx accelerator. Fifty patients who underwent lung SBRT treatment with DCA with FF were retrospectively analyzed using 6 MV FFF beams with dose rate of 1400 MU. We were observing the planning target volume (PTV) coverage, sparing of organ at risks (OARs) and time of treatment delivery. Results The PTV coverage (D98% > 95%) were similar, 98.3% vs 98% for FF and FFF, with 1887 MU’s vs 1860 MU’s, respectively. Dosimetric gain between FF and FFF for max dose to the heart was 1 Gy vs 0.87 Gy (p 0.0001). Max dose for spinal cord was 8.84 Gy vs 8.38 Gy (p 0.0001). Max dose for esophagus was 9.76 Gy vs 8.94 Gy (p 0.0001). Max dose for ribs was 34.16 Gy vs 31.89 Gy (p 0.0001). Time of treatment delivery was 4.50 min vs 2.43 min (p = 0.0006), for FF and FFF, respectively. Conclusion Treatment delivery with FFF DCA allows better sparing of OARs for SBRT of lung cancer patients. Shorter treatment time with FFF DCA for SBRT of lung cancer patients can reduce potentially discomfort or patient motion.

Resume Objectif de l’etude Rechercher dans la litterature des arguments permettant de guider dans le choix entre radiochirurgie et radiotherapie stereotaxique hypofractionnee dans le traitement des metastases cerebrales. Patients et methodes Quatre cent quarante-huit patients ont ete traites dans huit series par irradiation stereotaxique hypofractionnee avec une contention non invasive, une marge de securite de 2 a 10 mm (mediane 3 mm) a une dose de 24 a 40 Gy delivree en trois a cinq seances sur cinq a huit jours dans six series et 15–16 jours dans deux autres series, completant une irradiation encephalique totale de modalites variables dans 30 % des cas. Deux mille cent cinquante-sept patients ont ete traites dans 12 series recentes par radiochirurgie avec une contention invasive, sans marge perilesionnelle, a une dose de 10 a 25 Gy en une seule seance, completant une irradiation encephalique totale, le plus souvent de 30 Gy en dix fractions et 12 jours, dans des 58 % des cas. Les comparaisons ont porte sur les volumes tumoraux macroscopiques medians, la duree mediane de survie, les taux de survie a un an, de controle local et de toxicite. Resultats Pour les series de radiotherapie stereotaxique hypofractionnee, le volume tumoral macroscopique median etait de 0,52–4,47 cm 3 (mediane : 2,8 cm 3 ), la duree mediane de survie de cinq a 16 mois (mediane : 8,7 mois), le taux de survie a un an de 68,2 a 93 % (mediane : 82,5 %) et le taux de necrose de 3,1 %. Pour les series de radiochirurgie, le volume tumoral macroscopique median etait de 1,3 a 5,5 cm 3 (mediane : 2 cm 3 ), la duree mediane de survie de 5,5–22 mois (mediane : 11 mois), le taux de survie a un an de 71 a 95 % (mediane : 85 %) et la taux de necrose de 0,5 a 6 % (mediane : 2,4 %). La toxicite de la radiochirurgie est documentee dans les metastases volumineuses mais elle n’est pas connue pour la radiotherapie stereotaxique hypofractionnee. La marge de tissus sains incluse dans le volume cible previsionnel majore les risques de toxicite. L’association variable a une radiotherapie stereotaxique fractionnee rend l’interpretation des resultats difficile. Il s’agit d’une premiere etude exploratoire dont la methodologie est discutable. Conclusion Les volumes tumoraux macroscopiques ≤ 500 mm 3 (diametre de moins de 10 mm) necessitent une contention invasive et donc la radiochirurgie. Pour ceux de plus de 4200 mm 3 (diametre de 20 mm), la radiotherapie stereotaxique hypofractionnee parait preferable. La radiochirurgie ou la radiotherapie stereotaxique hypofractionnee sont utilisables pour les metastases cerebrales dont le volume tumoral macroscopique est compris entre 500 et 4200 mm 3 . Le fractionnement et l’etalement optimaux restent cependant a determiner.

Purpose: Retrospective comparison of Linac radiosurgery (RS) in 93 single brain metastases with or without a 2-mm margin. Patients and Methods: A total of 153 patients had Linac RS (between April 1992 and June 2004), with 139 patients (90.8%) evaluable in June 2005. Sixty-one patients (44%) had extracranial lesions and 65 patients had neurologic symptoms (47%). RS alone: 105 patients (66%); RS +whole brain radiotherapy: 34 patients (24%). Single metastasis: 93/139 patients; classic RS: 42/93 patients; 2-mm margin: 51/93 patients; 30 multiple lesions patients were excluded. Treatment: 15 Mv X-ray Linac, circular minibeams, 8-30 mm, four to six noncoplanar coronal arcs. Isodose was 60-80%; doses were 10-20 Gy. Follow-up: 12 months-13 years; median, 14 months. Results: Local control (LC) was not improved in 51 margin patients vs. 42 classic RS patients: 1 year: 69.1% and 72.4%. Two-year LC rate: 64% and 54.7%, respectively. Survival: median classic RS: 11.3 months; margin RS, 19 months (p = 0.34) and 1 year, 41.6% and 60.2%, respectively. Margin RS patients had a significantly higher rate of severe parenchymal complications: 19.6% vs. 7.1% (p = 0.02); surgery was necessary in 4 of 51 cases vs. 1 of 42 classic RS cases. Conclusion: No increase ofmore » 1- and 2-year LC rate in margin RS or survival and median survival: 11.3 vs. 19 months (NS) 2-mm margin associated with more severe parenchymal complications (p = 0.02).This procedure is therefore not recommended. Late CT images and 1-mm margin as recommended by pathologists, use of three-dimensional magnetic resonance imaging and fuzzy method to calculate volumes may yield better results. Stereotactic hypofractionation requires further studies.« less