Radiation dose to the low axilla in patients treated for early-stage breast cancer by locoregional intensity-modulated radiotherapy (IMRT).

PURPOSE: To determine the dose received by the low axilla during locoregional radiotherapy (RT) for early-stage breast cancer and to assess the impact of the treatment technique (three-dimensional conformal radiotherapy (3D-CRT) or rotational IMRT (VMAT) or helical tomotherapy (HT). MATERIALS AND METHODS: The dosimetric study was performed on patients receiving normofractionated (NFRT - 50Gy in 25 fractions) or hypofractionated (HFRT - 40Gy in 15 fractions) locoregional radiotherapy (breast or chest wall and internal mammary, supraclavicular and infraclavicular nodes±axillary nodes) by 3D-CRT or VMAT or HT at the Institut Curie Paris. Patients treated by breast-conserving surgery received a boost dose of 16Gy and 10Gy to the tumour bed, respectively. RESULTS: Sixty-eight patients treated by RT from February 2017 to January 2019 were studied. The mean dose received by the low axilla when it was not part of the target volume was 30.8Gy, 41.0Gy and 44.4Gy by 3D-CRT, VMAT and HT, respectively for NFRT and 24.2Gy, 33.0Gy and 34.9Gy, respectively, for HFRT. With NFRT, 4.1% of the axilla received 95% (V95) of the prescribed dose by 3D-CRT compared to 24.5% and 33.6% by VMAT and HT, respectively; with HFRT, V95 was 3.9%, 19.5% and 24.1%, respectively. CONCLUSION: The axilla receives a non-negligible dose during locoregional radiotherapy; this dose is greater when VMAT or HT are used. Prospective studies must be conducted to assess the impact of this axillary dose in terms of morbidity, which currently remains unknown.

Protontherapy versus best photon for mediastinal Hodgkin lymphoma: Dosimetry comparison and treatment using ILROG guidelines.

The purpose of this work was reducing treatment-related toxicity for Hodgkin lymphomas using practical procedure inspired by the ILROG guidelines. Reporting the first case of localized Hodgkin lymphoma treated with protontherapy in France. A 24-year-old female with mediastinal, bulky, localized, mixed-cellularity, classic Hodgkin lymphoma required an involved-site radiation therapy after complete response following polychemotherapy. Three-dimensional conformal radiation therapy was not acceptable due to high doses to breasts, heart and lungs. We realized a four-dimensional computed tomography (CT) to evaluate target movements and another CT with gating and breath-hold technique. Delineation was performed on both CT using the initial fluorodeoxyglucose positron-emission tomography/CT. One dosimetric plan with rotational intensity-modulated radiation therapy with a helical Tomotherapy© was realized and compared to another one with conformational protontherapy. Ninety-five percent of the planning target volume was covered by 98 and 99% of the prescribed dose with protontherapy and helical Tomotherapy©. Protontherapy provided the best organ at risk protection. Lung and heart protections were better with protontherapy: lung mean dose (3.7Gy vs. 8.4Gy) and median dose (0.002Gy vs. 6.9Gy), heart mean dose (2.6Gy vs. 3.7Gy). Breast sparing was better for both breasts using protontherapy: right breast mean dose (2.4Gy vs. 4.4Gy) and left (1.9Gy vs. 4.6Gy). The biggest difference was seen with low doses, which were better with protontherapy: volume of lung receiving 5Gy was 17.5% vs. 54.2% with Helical Tomotherapy©. In view of these results, we decided to treat our patient with protontherapy using respiratory assessment. We delivered 30Gy (15 fractions) using protontherapy with one direct anterior field using pencil beam scanning and deep inspiration breath-hold technique. We observed only grade 1 skin erythema during treatment and no toxicity during early follow-up.

Radiotherapy in combination with nivolumab for relapsed/refractory classical Hodgkin lymphoma: About two cases.

Hodgkin lymphoma is a highly curable malignancy involving lymph nodes and the lymphatic system. Even at late stage disease, about 70% of patients will be cured with standard first line therapy. For patients who experience relapse or refractory classical Hodgkin lymphoma, the standard treatment option is high-dose chemotherapy followed by autologous stem cell rescue or transplant. However about 50% of patients will have recurrence after high-dose chemotherapy followed by autologous stem cell rescue or transplantation and have worse prognosis with median overall survival of 32% at 5 years. The anti-PD1 checkpoints inhibitors pembrolizumab and nivolumab have remarkably improved outcomes of patients with relapse of refractory classical Hodgkin lymphoma after high-dose chemotherapy followed by autologous stem cell rescue or transplantation. On the other hand, radiotherapy is an entire component of salvage therapy and its efficacy is now well established in term of local disease control in sites of relapsed or refractory Hodkin lymphoma. Defining the optimal modality and timing of radiotherapy as these new agents arrive is a challenge. An interesting approach is the combination of radiotherapy with checkpoint inhibitor and the possibility of stopping the treatment when complete response is achieved. We add to the literature two new cases of combination of radiotherapy with immunotherapy in patients who relapsed after high-dose chemotherapy followed by autologous stem cell rescue or transplantation and consolidation with brentuximab vedotin, resulting in excellent outcomes.

[Prevalence and expectations of "alternative and complementary medicine" use during radiotherapy in 2016: A prospective study]. / Prévalence et attentes de l'utilisation des « médecines alternatives et complémentaires ¼ pendant la radiothérapie en 2016 : étude prospective.

PURPOSE: Alternative and complementary medicine is defined as any substance or technique of non-allopathic medicine used to improve health and quality of life. The purpose of this prospective observational study was to evaluate the use of alternative and complementary medicine during radiotherapy. MATERIAL AND METHODS: A questionnaire was given the last week of treatment to all patients treated for breast cancer, prostate cancer or head and neck cancer in our centre in 2016. RESULTS: In 2016, 132 patients were included. Fifty-seven patients (43%) used alternative and complementary medicine during radiotherapy, more women (61%) than men (35%) (P=0.005). The use of alternative and complementary medicine varied according to locations: 44% of head and neck cancers, 57% of breast cancers and 24% of prostate cancers, but sex was the confounding factor. If alternative and complementary medicine was used before radiotherapy, 82% of patients used it during treatment, compared to 30% if they were naive (P<10-7). Healing touch (68%), homeopathy (26%) and magnetisers (21%) were the most used alternative and complementary medicines. Sixty-one percent of patients used alternative and complementary medicine to reduce skin and mucosal side effects of treatments, 28% to improve well-being, and 9% to treat cancer. Seventy-two percent of all patients would advise their loved one to use an alternative and complementary medicine and 87% would like information about them in the hospital. CONCLUSION: Alternative and complementary medicines are used more by women, and by patients who used them before radiotherapy. The desired effects are mainly to reduce the side effects of the treatments. More than 80% of patients, whether or not they use alternative and complementary medicine, demand medical information.

[Evaluation of an automatic delineation system for organs at risk and target lymph nodes volumes for patients treated for breast cancer]. / Évaluation d'un logiciel pour la délinéation automatique des organes à risques et des volumes cibles ganglionnaires chez des patientes prises en charge pour un cancer du sein.

PURPOSE: Intensity-modulated radiotherapy needs the strict delineation of target volumes as well as organs at risk and the time used for this procedure is long. The purpose of this study was to evaluate the Workflow Box system (Mirada Medical, UK) for automatic delineation and segmentation for everyday use of organs at risk and lymph nodes delineation in patients treated for early stage breast cancer. MATERIAL AND METHODS: Twenty patients' CT scans in treatment position for their breast cancer radiotherapy were delineated in respect of the ESTRO delineation guidelines to begin the creation of automatic delineation atlas. Then 30 other CT scans were delineated this time by the automatic delineation system and by the radiation oncologist (reference delineation plan). The precision of the delineation was evaluated using the overlap volume index and evaluation of standard deviation (SD). RESULTS: The study of organs at risk has shown that the mean overlap volumes were between 0.49 (SD=0.21) and 0.97 (ET=0.03). Five organs at risk out of nine had overlap volumes at least 0.8. The mean overlap volume for all organs at risk was 0.77 (SD=0.17). The system was less performing for the lymph nodes with a mean overlap volume of 0.43 (SD=0.1) and ranging between 0.23 (SD=0.13) and 0.52 (SD=0.1). The use of this system reduced the delineation time by 40% per patient. CONCLUSIONS: For patients with breast cancer, the system for automatic delineation and segmentation Workflow Box (Mirada Medical, UK) permitted to safely shorten the time for delineation with acceptable organs at risk delineation. Improvement of lymph node volumes is needed. A new evaluation will be realized after using the system in routine practice.

[Adaptive radiation therapy for non-small cell lung cancer]. / Radiothérapie adaptative du carcinome bronchique non à petites cellules.

Anatomical changes and tumor regression during thoracic radiotherapy may alter the treatment volumes. These modifications are not taken into account into set-up or motion margins used for treatment planning. Their dosimetric impact could be significant and a better understanding of the changes occurring during the 6 to 7 weeks of treatment could be useful in order to define quantitative thresholds before a new treatment planning is needed. Margins could also be reduced in order to better spare organs at risk and perform targeted dose escalation. This review assesses the potential of morphologic and metabolic imaging during treatment for adaptive radiotherapy in non-small cell lung cancer.