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PURPOSE To describe the quality assurance (QA) program and early toxicities in the phase III randomized trial BONBIS (NCT00907868) on the role of a localized radiation boost in ductal carcinoma in situ (DCIS). MATERIALS AND METHODS From November 2008 to July 2014, 2004 patients were randomized in arm A (only whole breast radiotherapy, WBRT) and arm B (WBRT + boost). The QA program involved 44 participant centers that performed the dummy run (DR). Compliance and uniformity of clinical target volume (CTV) delineations, and dose prescription and delivery according to the BONBIS trial radiotherapy guidelines were analyzed. Acute toxicities (during and up to 3 months after radiotherapy completion, NCI-CTCAE v3.0 classification) were evaluated in 1929 patients. RESULTS The differences in whole breast CTV (CTV1) and planning target volume (PTV1) were ≤10%, and the differences in boost CTV (CTV2) and PTV (PTV2) were ≥20% compared with the reference DR values; 95% of the prescribed dose encompassed 98.7% and 100% of the median CTV1 and CTV2. Grade ≥2 breast erythema (38.3% vs. 22.4% of grade 2 and 5.4% vs. 2.1% of grade 3, p

We present the updated recommendations of the French society of oncological radiotherapy for rectal cancer radiotherapy. The standard treatment for locally advanced rectal cancer consists in chemoradiotherapy followed by radical surgery with total mesorectal resection and adjuvant chemotherapy according to nodal status. Although this strategy efficiently reduced local recurrences rates below 5% in expert centres, functional sequelae could not be avoided resulting in 20 to 30% morbidity rates. The early introduction of neoadjuvant chemotherapy has proven beneficial in recent trials, in terms of recurrence free and metastasis free survivals. Complete pathological responses were obtained in 15% of tumours treated by chemoradiation, even reaching up to 30% of tumours when neoadjuvant chemotherapy is associated to chemoradiotherapy. These good results question the relevance of systematic radical surgery in good responders. Personalized therapeutic strategies are now possible by improved imaging modalities with circumferential margin assessed by magnetic resonance imaging, by intensity modulated radiotherapy and by refining surgical techniques, and contribute to morbidity reduction. Keeping the same objectives, ongoing trials are now evaluating therapeutic de-escalation strategies, in particular rectal preservation for good responders after neoadjuvant treatment, or radiotherapy omission in selected cases (Greccar 12, Opera, Norad).

Adjuvant radiotherapy is one of the major anticancer treatments in early breast cancer patients. Acute and late radio-induced effects may occur during or after breast cancer radiotherapy, and their medical management is a major issue for radiation oncologists. Here, the present review of literature embraces complementary non-pharmacological interventions, which could be combined to adjuvant radiotherapy in order to improve patients care.

Introduction et but de l’etude Comparer les objectifs cliniques et la tolerance de la (chimio)radiotherapie chez des patients avec un carcinome epidermoide du canal anal selon l’infection par le virus de l’immunodeficience humaine (VIH). Materiel et methodes Il s’agissait d’une analyse en sous-groupe de la cohorte multicentrique, prospective et retrospective, Anabase, menee par la Federation francaise de cancerologie digestive (FFCD). Les objectifs cliniques incluaient la survie globale, la survie specifique, la survie sans recidive, le controle locoregional, la survie sans colostomie, le taux de reponse a 4–6 mois et la toxicite aigue et tardive severe (de grade 3 ou plus). Les facteurs pronostiques des principaux objectifs cliniques ont ete recherches. Resultats et analyse statistique Entre fevrier 2016 et avril 2020, 1097 patients atteints d’un carcinome epidermoide localise traite par irradiation ont ete inclus dans Anabase. Seuls les 488 patients avec un statut VIH connu ont ete inclus dans cette analyse (86 patients positifs et 402 patients negatifs issus de 50 centres). Le suivi median etait de 35,8 mois. Les caracteristiques tumorales initiales etaient comparables dans les deux groupes (stades T, X2 = 0,32 et N, X2 = 0,54). Les patients VIH-positifs etaient plus jeunes (p Tableau 1 et montrent que les taux de survie globale, controle locoregional et de survie sans colostomie etaient significativement diminues chez les patients infectes par le VIH. Il n’existait pas de difference significative pour la reponse a 4-6 mois, les taux de survie sans recidive et de survie specifique. La tolerance du traitement etait similaire dans les deux groupes (47,7 % de toxicite aigue de grade 3 ou plus chez les patients infectes par le VIH contre 45 % chez les patients non infectes, p = 0,65). Le sexe masculin, le statut OMS ≥ 1 et l’absence de reponse complete a 4–6 mois etaient associes a une survie globale diminuee en analyse uni- et multivariee. Conclusion Les patients infectes par le VIH recevant une (chimio)radiotherapie pour un carcinome epidermoide du canal anal avaient des taux de survie globale et sans colostomie inferieure a ceux des patients non infectes, ainsi qu’un controle locoregional moindre. La toxicite de ce traitement avec les techniques modernes d’irradiation conformationnelle avec modulation d’intensite n’etait pas majoree chez ces patients.

To evaluate our long-term experience on one-day breast intraoperative radiotherapy (IORT) given as sole radiation treatment to selected patients with breast cancer.Inclusion criteria of INTRAOBS study (prospective observational study) were: ER+ T1N0 unifocal ductal carcinoma; absence of lymphovascular invasion or of extensive intraductal component (Scarff-Bloom-Richardson grade III and HER2+++ excluded). Two different linacs were used (20Gy/1 fraction): one dedicated electron linac (October 2011), and afterwards a mobile linac (50kV photons). The primary endpoint was the local recurrence rate (=ipsilateral breast cancer recurrences number). Secondary endpoints were recurrence-free survival (RFS), overall and specific survival, cosmetic results, and patient satisfaction.Of the present pre-planned analysis for the first 200 patients (median age: 68 years; range, 59-87 years) who received IORT between January 2010 and October 2014 (median follow-up of 53.4 months). A total of 193 patients were still alive. The local recurrence rate was 2.5% (n=5). The 1- and 5-year local RFS rates were 100% and 95.2%, respectively. At 12 months post-surgery, satisfaction about IORT was excellent for 86.9% of patients. Cosmetic results were considered by patients and physicians as good or very good in 89.4% and 97.3% of cases, respectively.IORT for selected patients with breast cancer shows low recurrence rates, good cosmetic outcomes and excellent satisfaction.

Purpose To determine the 3 years late toxicity among patients with non-metastatic breast cancer who received concurrent bevacizumab and locoregional radiotherapy. Material and methods This is a single-arm, multicentre, prospective study, of the toxicity of adjuvant concomitant association of bevacizumab and radiotherapy in patients with breast cancer. Toxicity was assessed by the Common Terminology Criteria for Adverse Events version 3.0 during the radiotherapy and follow-up clinics at 12 and 36 months after its completion. The study was designed to evaluate the toxicity at one year, 3 years and 5 years. Results Sixty-four patients were included from October 2007 to August 2010. All of them received concurrent adjuvant radiotherapy and bevacizumab (in 24 cases after primary systemic treatment). All patients received non-fractionated radiotherapy to breast or chest wall with or without irradiation of regional lymph nodes. Early toxicity has been previously reported. Median follow-up was 46.4 months (range: 18–77 months). Median age was 53 years old (range: 23–68 years). The 3-years overall survival was 93% (range: 87–100%). Evaluation of the toxicity at 3 years was available for 67% of the patients. There was a low rate of toxicity: 14% grade 1 pain, 9% grade 1 fibrosis, 2% grade 1 telangiectasia, 2% grade 1 paresis, 7% grade 1 lymphedema and 2% grade 3 lymphedema. No grade 4 toxicity was observed. No patient had a left ventricular ejection fraction below 50% at 3 years. Conclusions Concurrent bevacizumab with locoregional radiotherapy is associated with acceptable 3-years toxicity in patients with breast cancer.

Standard of care in breast cancer management is well-defined. However, some gray zones still exist, in particular adjuvant radiotherapy indications in case of pN1mi breast cancer. Here we propose to define their prognosis, to underpin the benefit of adjuvant treatments in such patients' management and to define lymphedema risk, which is the most common late side effect of locoregional treatments.

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.

Resume Nous proposons dans cette revue de rapporter l’impact de la radiotherapie stereotaxique chez les patients ayant un cancer oligometastatique ou en oligoprogression en termes de survie sans progression metastatique et globale, et d’identifier quelle est la place de cette modalite de radiotherapie au sein du parcours–patient.

IF 4.942 (2017); International audience

Introduction et but de l’etude Le second traitement conservateur emerge comme une option therapeutique en cas de second evenement tumoral du sein homolateral apres chirurgie conservatrice et irradiation du sein. Nous rapportons les resultats d’une comparaison entre second traitement conservateur et mastectomie de rattrapage en cas de second evenement tumoral du sein homolateral. Materiel et methodes Les resultats oncologiques apres le traitement d’un second evenement tumoral du sein homolateral ont ete analyses par etude appariee (score de propension) pour des patients atteints d’un second evenement tumoral du sein homolateral diagnostique entre 01/2000 et 12/2014. Le second traitement conservateur etait soit une tumorectomie et une curietherapie, soit une mastectomie. L’appariement (1 :1) a ete realise par la methode du “nearest neighbor” (incluant les donnees relatives au second evenement tumoral du sein homolateral : âge, intervalle entre le premier et le second evenement tumoral du sein homolateral, taille tumorale, type et grade histologique, expression des recepteurs hormonaux et Her2, chimiotherapie, hormonotherapie et periode du second evenement tumoral du sein homolateral). L’objectif primaire etait la survie sans maladie. Les objectifs secondaires etaient la survie globale, la survie sans metastase et la survie sans troisieme evenement tumoral du sein homolateral. Resultats et analyse statistique Parmi les 1329 patientes dont les dossiers ont ete analyses (mastectectomie : 942 ; second evenement tumoral du sein homolateral : 387), 430 ont ete appariees par score de propension (mastectectomie : 215/2 ; second traitement conservateur : 215). Le suivi median etait de 65 mois pour la mastectectomie (intervalle de confiance a 95 % [IC 95 %] : [58-78]) et de 68 mois (IC 95 % : [57-75]) pour le second traitement conservateur (p = 0,28). En analyse appariee, il n’y avait aucune difference a 5 ans pour la survie sans maladie entre la mastectomie et le second traitement conservateur (78 % ; IC 95 % : [71-84]) contre (82 % ; IC 95 % : [76–89] ; p = 0,22). Aucune difference a 5 ans n’a ete observee pour la survie globale (90 %, IC 95 % : [86–95]) contre 86 %, (IC95 % : [81–92] ; p = 0,85), la survie sans metastase (92 %, IC 95 % : [87–96]) contre 94 %, (IC 95 % : [90–98] ; p = 0,75) et la survie sans troisieme evenement tumoral du sein homolateral (94 %, IC 95 % : [90–98]) contre 98 %, (IC 95 % : [95–1] ; p = 0,17). Conclusion Il s’agit de l’analyse appariee la plus importante entre la mastectomie et le second traitement conservateur en cas de second evenement tumoral du sein homolateral. Compare a la mastectomie, le second traitement conservateur (tumorectomie avec curietherapie) ne semble pas etre associe a une difference significative en termes de survie sans maladie, survie globale, survie sans metastase et survie sans troisieme evenement tumoral du sein homolateral. Le second traitement conservateur peut donc etre considere comme une option de traitement de rattrapage.

In addition to achieve breast conserving surgery after neoadjuvant chemotherapy, its indications are growing, especially in Her2 overexpressing and triple negative breast cancers owing to the emergence of new targeted therapies. Radiotherapy belongs to breast cancer management. However, some questions are still unresolved regarding nodes area irradiation after neoadjuvant chemotherapy. This short communication reviews indications of radiotherapy of node areas in breast cancer after neoadjuvant chemotherapy.

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.

IF 4.328; International audience

Hormone receptors are expressed in more than 75% of breast cancer. Therefore, two prescription modalities of endocrine therapy could be proposed: either sequential or concomitant to breast cancer irradiation. If combined to radiotherapy, is endocrine therapy a radiosensitizer? Does endocrine therapy enhance the risk factor of radio-induced toxicity? Here, we will distinguish the interaction of ionizing radiation combined with therapies targeting oestrogen receptor (REα) from the interaction of ionizing radiation with oestrogen. This review aims at making clear all these items.

International audience; 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.

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.

Objectif de l’etude Il s’agissait de demontrer la faisabilite d’utilisation de marges de volume cible previsionnel reduites a 5 mm lors d’une radiotherapie conformationnelle avec modulation d’intensite (RCMI) et guidee par l’image de cancers de l’œsophage. Materiel et methode Nous avons inclus dans cette etude les patients pris en charge en 2016 par RCMI pour un cancer primitif de l’œsophage cervical ou thoracique, de tout stade TNM et de tout type histologique. Des marges de volume cible previsionnel reduites a 5 mm dans toutes les directions ont ete etudiees retrospectivement. Le guidage par l’image a ete realise quotidiennement, soit par deux images orthogonales de basse energie (kV-kV), soit par tomographie conique (CBCT). Le recalage a ete realise par un manipulateur d’electroradiologie medicale. L’ensemble des recalages realises a l’aide des tomographies coniques ont ete regardes a posteriori par un medecin afin de verifier la couverture tumorale par ce volume cible previsionnel reduit, et les differences de recalage ont ete relevees entre manipulateur et medecin dans les trois plans de l’espace. Resultats Trente patients ont ete inclus. Il y avait 18 carcinomes epidermoides (60 %), huit adenocarcinomes (27 %) et trois carcinomes neuroendocrines (10 %). La localisation etait l’œsophage thoracique dans 93 % des cas (10 % le tiers superieur, 33 % le tiers moyen, 30 % le tiers inferieur, 20 % les tiers moyen et inferieur), et cervical dans 7 % des cas. Apres tomographie conique, 145 recalages ont ete verifies (deux a cinq par patient, au maximum un par semaine). La couverture tumorale par le volume cible previsionnel etait assuree dans 61 % des cas avant la tomographie conique et dans 95 % des cas apres. La couverture tumorale n’etait pas satisfaisante dans sept tomographies coniques, pour cinq patients differents. Les differences de recalage entre manipulateur et medecin dans les trois plans de l’espace etaient inferieures a 5 mm dans 96 % des cas. Le maximum de difference de recalage a ete retrouve pour le tiers inferieur de l’œsophage thoracique. Conclusion Une marge de volume cible previsionnel de 5 mm semble suffisante pour la RCMI des cancers de l’œsophage en cas de guidage par l’image par tomographie conique. Un suivi carcinologique a long terme est necessaire.

Objectif de l’etude Evaluation des pratiques, traitements et resultats des cancers du canal anal dans la cohorte nationale Anabase. Materiel et methode Cette cohorte observationnelle multicentrique a inclus tous les patients pris en charge pour un carcinome du canal anal dans 62 centres francais depuis janvier 2015. Nous presentons les caracteristiques des patients et des tumeurs, les traitements et les resultats, ainsi que les facteurs associes a la reponse complete a 6 mois en analyse uni- et multifactorielle. Resultats Entre janvier 2015 et fevrier 2018, 448 patients ont ete pris en charge pour un carcinome du canal anal non metastatique par radiotherapie ou chimioradiotherapie : 106 hommes (23,6 %) et 342 femmes (76,4 %), d’âge median 64 ans [35–97]. Les tumeurs etaient limitees (T1-2, N0, M0) pour 197 patients (44 %) et localement evoluees (T3-4 ou N+, M0) pour 251 (56 %). Une chimioradiotherapie a ete delivree a 348 patients (77,7 %), avec une chimiotherapie a base de mitomycine (86 %), de cisplatine (4 %) ou de 5-fluoro-uracile seul (8 %), et une chimiotherapie neoadjuvante a 40 patients (8,8 %). La radiotherapie etait conformationnelle avec modulation d’intensite (RCMI ; 83 %) ou conformationnelle tridimensionnelle (17 %) avec une dose totale mediane de 60 Gy [extremes : 14–71 Gy] et une interruption pour 170 patients (planifiee : 59 %). Six mois apres radiotherapie, parmi 350 patients, 72 % etaient en situation de reponse complete, 18 % de reponse partielle ou de stabilisation et 10 % de progression. Les facteurs associes a la reponse complete a 6 mois en analyse unifactorielle etaient le stade initial limite (Odds ratio [OR] = 1,8, intervalle de confiance a 95 % [IC 95 %] = 1,1–3,0, p = 0,013), la taille tumorale de moins de 3 cm (OR = 2,2, 95 %IC = 1,2–3,9, p = 0,009), alors que la chimiotherapie neoadjuvante (OR = 0,4, IC 95 % = 0,2–0,7, p = 0,003) et la dose de radiotherapie ( Conclusion Les premiers resultats de la cohorte Anabase montrent une bonne adequation aux recommandations (RCMI, chimiotherapie a base de mitomycine). Neanmoins, une pause planifiee et une chimiotherapie neoadjuvante sont encore pratiquees dans certains centres.

Resume Objectif Evaluer l’apport de la TEP-FDG dans la prise en charge du cancer du canal anal et tout particulierement son impact sur la strategie therapeutique. Materiel et methodes Entre mars 2005 et aout 2008, 48 TEP ont ete realisees chez 43 patients porteurs d’un carcinome epidermoide anal, pour bilan d’extension initial (BEI : 20 examens), evaluation de la reponse therapeutique (ERT : 11) et bilan de recidive (BR : 17). Nous avons compare les strategies therapeutiques initiales definies sur les resultats du bilan conventionnel et finales retenues au decours de la TEP. Resultats La TEP a decele des lesions meconnues par le bilan conventionnel dans 23 % des cas (BEI : 25 % ; ERT : 18 % ; BR : 23 %) et dedouane des lesions suspectes dans 21 % des cas (BEI : 10 % ; ERT : 18 % ; BR : 35 %). Elle a influence la strategie therapeutique et l’a modifiee parfois meme radicalement, dans 44 % des cas (BEI : 35 % ; ERT : 54 % ; BR : 47 %). Cet impact therapeutique etait surtout marque dans les situations presentant une ambiguite diagnostique, ou la TEP permettait de preciser ce diagnostic et d’orienter en consequence le choix therapeutique. Conclusion La TEP presente un interet dans la prise en charge du cancer du canal anal, particulierement dans les situations diagnostiques douteuses, ou les informations metaboliques apportees permettent d’influencer le choix therapeutique dans pres de la moitie des cas.

Ductal carcinoma in situ is defined as breast cancer confined to the ducts of the breast without evidence of penetration of the basement membrane. Local treatment quality represents one of the most prognostic factors as half of recurrences are invasive diseases. The main goal of adjuvant radiotherapy after conservative surgery is to decrease local recurrences and to permit breast conservation with low treatment-induced sequelae. Several randomized trials have established the impact of 50 Gy to the whole breast in terms of local control. Nevertheless, no randomized trial is still available concerning the role of the boost in this disease. In this review, we present updated results of the literature and we detail the French multicentric randomized trial evaluating the impact of a 16 Gy boost after 50 Gy delivered to the whole breast in 25 fractions and 33 days. This protocol will start inclusions in October 2008.

Combined radiation and hormone therapies have become common clinical practice in recent years for locally-advanced prostate cancers. The use of such concomitant therapy in the treatment of breast disease has been infrequently reported in the literature, but seems justified given the common hormonal dependence of breast cancer and the potential synergistic effect of these two treatment modalities. As adjuvant therapy, two strategies are used in daily clinical practice: upfront aromatase inhibitors or sequentially after a variable delay of tamoxifen. These molecules may, thus, interact with radiotherapy. Retrospectives studies recently published did not show any differences in terms of locoregional recurrences between concurrent or sequential radiohormonotherapy. Lung and skin fibroses due to concurrent treatment are still under debate. Nevertheless, late side effects appeared to be increased by such a treatment, particularly in hypersensitive patients identified at risk by the lymphocyte predictive test. Concurrent radiohormonotherapy should, thus, be delivered cautiously at least for these patients. This article details the potent advantages and risks of concurrent use of adjuvant hormonotherapy and radiotherapy in localized breast cancers.

International audience; BACKGROUND:Accelerated partial breast irradiation (APBI) is an option for adjuvant radiotherapy according to ASTRO and ESTRO recommendations. Among the available techniques, volumetric-modulated arc therapy (VMAT) is attractive but has not been extensively studied for APBI. This study assessed its feasibility, tolerance and early oncological outcomes.METHODS:We analysed the data of nine patients (median age 74 years) with ten lesions (one bilateral cancer) treated from May 2011 to July 2012 with APBI using VMAT. The radiation oncologist delineated the surgical tumour bed, and added an 18 mm isotropic margin to obtain the planning target volume (PTV). The dose was 40 Gy prescribed in 4 Gy fractions given twice a day over five days. Patients were regularly followed for toxicities and oncological outcomes.RESULTS:Mean PTV was 100.0 cm(3) and 95 % of the PTV received a mean dose of 99.7 % of the prescribed dose. Hot spots represented 0.3 % of the PTV. 6.2 %, 1.6 % and 0.3 % of the ipsilateral lung volume received 5 Gy (V5Gy), 10 Gy (V10Gy) and 20 Gy (V20Gy), respectively. Regarding the contralateral lung, V5Gy was 0.3 %, and V10Gy and V20Gy were nil. V5Gy accounted for 3.1 % of the heart. An average 580 monitor units were delivered. No acute or late grade ≥ 2 toxicities were observed. With a median follow-up of 26 months, no relapses occurred.CONCLUSION:In our study, VMAT allowed optimal dosimetry with consequential high therapeutic ratio in elderly and frail patients.

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.

Resume L'hormonoradiotherapie (concomitante) est utilisee depuis plusieurs annees en pratique clinique quotidienne dans les cancers localement evolues de la prostate. Le transfert de ce concept en pathologie mammaire a ete tres peu rapporte dans la litterature mais semble pourtant licite devant l'hormono-dependance frequente des cancers du sein et la synergie potentielle de ces deux armes therapeutiques. En situation adjuvante, le tamoxifene est la molecule de reference du traitement antihormonal avec un avantage significatif, tant sur le taux de recidives locales que sur la survie globale. Les inhibiteurs de l'aromatase sont en cours d'evaluation dans cette indication et les premiers resultats sont prometteurs. In vitro, le tamoxifene ne semble pas avoir un effet cytoprotecteur vis-a-vis de la radiotherapie. En clinique, le peu d'essais publies confirment la superiorite de l'association concomitante de la radiotherapie et du tamoxifene par rapport a la radiotherapie seule en termes de taux de controle local apres chirurgie conservatrice. Avec l'association radiotherapie–tamoxifene, les donnees rapportees dans la litterature sont moins controversees pour la majoration de la fibrose pulmonaire que pour la fibrose sous-cutanee et son retentissement sur les resultats cosmetiques. L'association concomitante de la radiotherapie et des inhibiteurs de l'aromatase reste encore tres peu decrite dans la litterature. Le letrozole (Femara ® ) presente un effet radiosensibilisateur sur des lignees de cancer du sein transfectees par le gene de l'aromatase. Aucune donnee clinique concernant l'association radiotherapie–letrozole n'est actuellement disponible. Dans l'etude FEMTABIG ( Femara-Tamoxifen Breast International Group ), la sequence de la radiotherapie et du traitement hormonal etait libre (letrozole contre tamoxifene contre traitement sequentiel). L'etude ATAC ( Arimidex Tamoxifen Alone or in Combination ) a recemment demontre que l'anastrozole (Arimidex ® ) etait superieur au tamoxifene en situation adjuvante, mais elle ne renseigne pas sur le nombre de patients traites par l'association radiotherapie–anastrozole. Dans l'etude TEAM, comparant l'exemestane (Aromasine ® ) au tamoxifene, le traitement hormonal debutait obligatoirement apres la fin de la radiotherapie.

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.

International audience

Background The Montpellier cancer institute phase II trial started in 2004 and evaluated the feasibility of intraoperative radiotherapy (IORT) technique given as a sole radiation treatment for patients with an excellent prognostic and very low recurrence risk. Methods Forty-two patients were included between 2004 and 2007. Inclusion criteria were patients ≥ 65 years old, T0-T1, N0, ductal invasive unifocal carcinoma, free-margin > 2 mm. IORT was delivered using dedicated linear accelerator. One fraction of 21 Gy was prescribed and specified at the 90% isodose using electrons. In vivo dosimetry was performed for all patients. Primary end-point was the quality index. Secondary endpoints were quality of life, local recurrences, cosmetic results, specific and overall survival. Results At inclusion, median age was 72 years (range, 66–80). Median tumor diameter was 10 mm. All patients received the total prescribed dose. No acute grade 3 toxicities were observed. Late cosmetic results were good at 5 years despite the poor agreement of accuracy assessment between patients and physicians. Four patients (9.5%) experienced a local failure and underwent salvage mastectomy. The 5 year-disease free survival is 92.7% (range 79.1−97.6). All patients are still alive with a median follow-up of 72 months (range 66–74). Conclusion Our results confirm with a long-term follow-up that exclusive partial breast IORT is feasible for early-breast cancer in selected patients. IORT provides good late cosmetics results and should be considered as a safe and very comfortable “one-step” treatment procedure. Nevertheless, patient assessments are essential for long-term quality results.

Objectif de l’etude Evaluer le devenir a long terme de patients pris en charge pour un carcinome anal par radiotherapie conformationnelle avec modulation d’intensite (RCMI). Materiel et methode Entre aout 2007 et septembre 2015, 233 patients atteints d’un carcinome epidermoide du canal anal ont ete pris en chage par RCMI, notamment par arctherapie volumetrique depuis 2009. L’irradiation delivrait 45 Gy en 25 fractions d’1,8 Gy, cinq jours par semaine, a la tumeur initiale et aux aires ganglionnaires pelviennes et inguinales (premier volume cible previsionnel, PTV1). Un boost (non integre) de 14,4 a 20 Gy etait ensuite administre a la tumeur initiale (deuxieme volume cible previsionnel, PTV2), par fractions de 1,8-2 Gy ou par curietherapie. Les tumeurs localement evoluees recevaient une chimiotherapie concomitante par 5-fluoro-uracile-mitomycine ou 5-fluoro-uracile -cisplatine. La toxicite a ete etudiee avec l’echelle Common Terminology Criteria for Adverse Events, version 4.0. L’etude des 166 premiers patients est presentee ici. Resultats Les dossiers de 124 femmes (75 %) et 42 hommes (25 %) ont ete analyses. L’âge median etait 61 ans (36–92 ans). Les tumeurs etaient de stades I, II, III et IV chez respectivement 13 %, 25 %, 57 % et 4 % des patients. Treize etaient immunodeprimes, dont dix infectes par le virus de l’immunodeficience humaine (6 %), 132 (80 %) ont recu une chimioradiotherapie et 34 (20 %) une radiotherapie seule. Avec un suivi median de 46,7 mois (intervalle de confince a 95 % [IC95 %] : 41,2–51,6, aucune toxicite tardive de grade 4 n’a ete observee. Vingt patients (12 %) ont souffert d’une toxicite de grade 3, diarrhee, rectite, hematurie, radiodermite, incontinence anale et/ou stenose vaginale. Il n’y avait pas de toxicite hematologique tardive significative ( p = 0,23). Trente-six cancers (22 %) ont recidive, 24 locoregionalement (67 %), 12 a distance isolement (33 %). Trente-trois patients (20 %) ont ete colostomises apres la radiotherapie, dont 17 pour recidive locale et 12 pour toxicite radioinduite. Le taux de survie globale a 3 ans etait de 85,5 % (IC95 % : 78,7–90,3), celui sans recidive locoregionale de 86,9 % (IC95 % : 80,3–91,4), celui sans maladie de 74,6 % (IC95 % : 67,0–80,8) et celui sans colostomie de 81,2 % (IC95 % : 74,0–86,6). Conclusion La RCMI devient un traitement standard des cancers du canal anal. Une analyse dosimetrique completera ces resultats.

Purpose Ductal carcinoma in situ overall prognosis is excellent, but after breast conserving surgery, with or without radiotherapy, local recurrences can lead to locoregional or distant evolution and death. However, there are few data on optimal local recurrences treatment and long-term impact on survival. Patients and methods This study included 195 women treated from 1985 to 1996 by conservative surgery (CS) or conservative surgery followed by radiotherapy (CS + RT), presenting local recurrences, with a 156-month median follow-up. Results Eighty-two out of 195 (42%) local recurrences were non-invasive (in situ) and 113 (58%) invasive. In situ local recurrence was discovered by mammography in 80.5% of the cases versus 47.5% for invasive local recurrence (P = 0.0001). Salvage mastectomy was used in 53% of the cases after conservative surgery and 75% after conservative surgery followed by radiotherapy. The axillary nodal involvement rates were 11.8% and 25.8% among 17 and 62 patients with in situ and invasive local recurrences. Among 113 patients with invasive local recurrences and 82 with in situ local recurrences, 19 (16.8%) and three (3.6%) developed metastases, respectively. Among invasive local recurrences, comedocarcinoma subtype was highly predictive of subsequent metastases (32% versus 4.4%, P Conclusion Invasive local recurrence after ductal carcinoma in situ treatment could be a dramatic event, fully changing long-term prognosis. Early mammographic local recurrence diagnosis (if possible still at non-invasive stage) seems essential to avoid or minimize metastatic risk. Mastectomy remains the safest option but, in some cases, a new conservative approach could be discussed.

Objectif Analyser les resultats cliniques et dosimetriques de la tomotherapie helicoidale et du RapidArc™ dans les irradiations mammaires et ganglionnaires adjuvante complexe (incluant les aires ganglionnaires, la chaine mammaire interne) avec boost integre. Patientes et methodes Soixante-dix-neuf patientes ont ete incluses dans l’etude. Le traitement a ete pour 37 une tomotherapie et 42 par RapidArc™. Il a ete delivre en 29 fractions. Les prescriptions de dose dans le boost etaient de 63,8 Gy (tomotherapie) et 63,2 (RapidArc™), dans le sein de 52,2 Gy (tomotherapie et Rapidarc™) de 50,4 dans aires ganglionnaires et la chaine mammaire interne avec la tomotherapie et de 52,2 Gy et 49,3 Gy avec le RapidArc™. Les deux cohortes n’utilisaient pas les memes marges pour definir les volumes cibles previsionnels. Resultats Avec la tomotherapie, le volume cible anatomoclinique du lit tumoral recevant 95 % de la dose prescrite (V95) etait de 99,4 % ± 2,4, celui du sein de 97,8 % ± 5,1, celui sus- et sous-claviculaire de 99,4 % ± 16,8 et celui mammaire interne de 96,5 % ± 21,2 pour. Avec le RapidArc™, les valeurs etaient respectivement de 99,7 % ± 0,5, 99,3 % ± 0,7, 99,6 % ± 1,4 et de 99,3 % ± 3. Pour le poumon homolateral, la dose moyenne et le volume recevant 20 Gy (V20) etaient respectivement de 13,5 Gy ± 1,4, 20,9 % ± 4,9 (avec la tomotherapie et de 13,6 Gy ± 1,4, 20,1 % ± 3,2 avec le RapidArc™). Pour le cœur, la dose moyenne et le volume recevant 30 Gy (V30) etaient de 7,4 Gy ± 1,4 et 1 % ± 1 avec la tomotherapie et de 10,3 Gy ± 4,2 et 2,5 % ± 3,9 avec le RapidArc™. Pour le sein controlateral, la dose moyenne etait de 3,6 Gy ± 0,7 avec la tomotherapie et de 4,6 Gy ± 0,9 avec le RapidArc™. Il y a eu 5 % de cas de toxicite cutanee aigue de grade 3 ou plus dans les deux cohortes et 35 % de toxicite aigue œsophagienne de grade 1 ou 2 avec la tomotherapie et 40 % avec le RapidArc™. Conclusions La RCMI rotationelle dans les irradiations mammaires et ganglionnaires complexe permet une bonne couverture des volumes cibles avec une tolerance aigue acceptable. Un recul plus important est necessaire pour evaluer l’impact des faibles doses sur les tissus sains.

Our aim was to identify risk factors for aspiration following concurrent chemoradiation for oropharyngeal cancer. 46 patients with locally advanced oropharyngeal carcinoma underwent concurrent chemoradiation at our institution. All patients underwent modified barium swallow to assess dysphagia severity and to determine the need for continued tube feedings after treatment. Dysphagia severity was graded as 1-7. There were 5 Grade 2, 11 Grade 3, 5 Grade 4, 5 Grade 5, 10 Grade 6 and 10 Grade 7 scores. 25 patients (54%) developed aspiration (5 trace, 20 severe). The aspiration rate for T1-T2 and T3-T4 tumours was 31% and 67%, respectively (p = 0.03). There was no statistical difference in the aspiration rate between the base of the tongue and tonsillar carcinoma (p = 0.23). Despite anatomical organ preservation, most patients with locally advanced oropharyngeal carcinoma had moderate to severe dysphagia after chemoradiation. Patients with large tumours had a significant risk of developing aspiration following treatment.

Objective The purpose of the study is to evaluate dysphagia severity following chemoradiation and postoperative radiation for head and neck cancer, and particularly the aspiration risk because of its potential life-threatening consequence. Materials and methods We reviewed retrospectively the modified barium swallow (MBS) results in 110 patients who complained of dysphagia following chemoradiation (57) and postoperative radiation (53) of their head and neck cancer. Patients were selected if they were cancer free at the time of the swallowing study. Dysphagia severity was graded on a scale of 1–7. Patients were grouped according to the dysphagia severity: mild (grades 2–3), moderate (grades 4–5), and severe (grades 6–7). Results Mean and median dysphagia grades were 4.84/5 and 4.12/4 for chemoradiation and postoperative radiation respectively. The mean difference between the two groups is statistically significant ( p = 0.02). Mild dysphagia occurred in 13 patients (22%) of the chemoradiation group and 17 (32%) of the postoperative group. Corresponding number for the moderate group was 25 (43%) and 25 (48%), respectively. Severe dysphagia was significant in the chemoradiation group (34%) compared to the postoperative group (19%). However, the difference was not statistically significant ( p = 0.29). There was a higher proportion of patients with large tumor (T3–T4) in the chemoradiation group who developed severe dysphagia. Conclusion Dysphagia remained a significant morbidity of chemoradiation and postoperative radiation for head and neck cancer. Dysphagia may be more severe in the chemoradiation group because of the higher proportion of patients with large tumor, the high radiation dose, and a high number of oropharyngeal tumors. Aspiration occurred in both groups. Diagnostic studies such as MBS should be part of future head and neck cancer prospective studies to assess the prevalence of aspiration, as it may be silent.