[Place of radiation-therapy of breast cancer treatment--current and future indications]. / Place de la radiothérapie dans le traitement du cancer du sein. Indications actuelles et perspectives.

Radiotherapy is an important part of breast cancer treatment. After breast conserving surgery, a dose of 50 Grays (Gy) is administered to the entire breast. Boost by external radiotherapy or brachytherapy improves local control especially for women under fifty. For lobular in situ lesions, no additional treatment is required, while intraductal lesions are treated with post-operative radiotherapy in case of Van Nuys score of 7, 8 or 9. After mastectomy, irradiation is proposed in case of skin involvement, invasion of pectoral muscle, positivity of at least 3 axillary lymph nodes, SBR III grade, T3 stage or multifocality where the sum of tumour diameters are >5 cm. Irradiation of the axilla has become exceptional. In node positive patients, the supraclavicular region receives 50 Gy with low energy photons, whereas the internal mammary chain is treated at the same dose but half is administered by low energy photons et half by electrons. Exclusive or preoperative irradiation is rare, because of new chemotherapy schedules, new drugs and hormonotherapy developments. Neoadjuvant chemotherapy enhances possibilities of conservative surgery it is followed by radiotherapy depending on the same indiciations listed above. Re-irradiation is possible but one must be aware of the higher risk of late toxicity. Nowadays, major side-effects are rare but close follow-up during and after treatment is required from the radiation oncologist to detect, evaluate, prevent and even treat possible complications.

[Partial breast irradiation: the role of brachytherapy. A new treatment option for early breast cancer]. / L'irradiation partielle du sein et le rôle de la curiethérapie: une nouvelle approche thérapeutique pour les carcinomes mammaires de bon pronostic.

Early breast cancer can be treated by conservative surgery followed by partial breast irradiation. This recent treatment replaces classical external beam whole breast radiotherapy. Several techniques are available but most experience does exist with interstitial catheter based brachytherapy. This well tolerated treatment shortens the treatment time and offers a good local control and cosmetic outcome, comparable to the best classical treatments, as confirmed by the first published results. These good results can only be obtained by rigorous patient selection and very precise 3D imaging and source implantation techniques.

192Ir or 125I prostate brachytherapy as a boost to external beam radiotherapy in locally advanced prostatic cancer: a dosimetric point of view.

PURPOSE: This work aims at comparing the dosimetric possibilities of 125I or 192Ir prostate brachytherapy (Bt) as a boost to external beam radiotherapy in the treatment of locally advanced adenocarcinoma. METHODS AND MATERIALS: From 1/1997 to 12/2002, 260 patients were treated. Until 12/2001 a low dose rate (LDR) treatment with 192Ir wires was used, later replaced by a high dose rate (HDR) delivered with an 192Ir stepping source technology. For the present work, we selected 40 patients including the last 20 treated, respectively, by LDR and HDR. The planning CT Scans of all these 40 patients were transferred into the 3D Prowess system for 125I permanent implants design according to the Seattle method. The reference data for dosimetric comparisons were the V100 and the prescribed dose for 192Ir as well as the dose delivered with 125I techniques to the 192Ir V100. We compared V100-150 data as well as doses to the organs at risks (OR) and cold spots (CS). RESULTS: The V100 is 85.3+/-8% for 192Ir LDR and 96+/-2% for HDR techniques (P < 0.0001). In comparison with 125I, the 192Ir LDR mode induces higher hyperdosage volumes inside the CTV but also more CS, while maximal doses to urethra and rectum are, respectively, 17 and 39% less with 125I (P < 0.0001). In comparison with the 192Ir HDR mode, 125I Bt induces higher hyperdosage volumes and slightly more CS deliberately planned around the bladder neck. If delivered doses to urethra are identical, those to the 20% anterior part of the rectum are 33% less with 125I (P < 0,0001). The 125I Bt technique was only possible in 24 out of the 40 patients studied due to pelvic bone arch interference. CONCLUSIONS: At the present time, there is no evident dosimetric superiority of one Bt method when all the criteria are taken into account. However, improving Bt techniques to implant any prostatic size could found the superiority of the 125I or permanent implants. 125I indeed allows large hyperdosage volumes inside the CTV in comparison with 192Ir HDR techniques while lowering doses to OR and minimizing CS.

[How I treat...oropharyngeal mucositis associated with radiotherapy for head and neck cancer]. / Comment je traite ... la mucite bucco-pharyngée lors d'une radiothérapie cervico-faciale.

Oral mucositis the major acute effect of head and neck radiotherapy. According to the degree, irradiation may be compromised in dose and overall time with consequences on outcome. Up to now there is no standard accepted protocol. A strict program of local and general hygiene is mandatory. Analgesics are often required. Amifostine acts as a protector of salivary glands GM-CSF and G-CSF stimulate proliferation of mucosal basal cells. Sucralfate plays a barrier role. Camomile plant extract is anti-inflammatory, well tolerated and cheap. Povidone-iodine is better than chlorhexidine as an antiseptic agent. PTA lozenges with polymixin E, tobramycin and amphotericin B showed a marked power of selective microbial decontamination.

[Prostate brachytherapy: current states and future prospects]. / La curiethérapie prostatique: réalités et perspectives.

The paper presents the characteristics, the place and the limits of brachytherapy in prostate radiotherapy. While sparing the rectal wall, erectile function as well as urinary continence, I(125) and Pd(103) permanent implants represent interesting approaches for good prognosis tumours in comparison to surgery or conformal external beam radiotherapy with similar cure rates. Overcoming easily the problems of organ motion and patient positioning while allowing doses per fraction as high as 10 Gy, brachytherapy is an excellent boosting method in the treatment of intermediate or unfavourable prognosis tumours of which alpha/beta is 1,5 Gy. Encouraging biological control rates of 80-90% have been published in phase II trials. Compared to external beam radiotherapy, the heterogeneity of irradiation inside the clinical target volume should increase the probability of cure as for a specific dose, a significant part will be overdosed. So far, 120-130% of the prescribed doses are delivered to the peripheral zone at the origin of 70% of tumours. On the opposite, this heterogeneity is inducing an overdosage of the urethral bed at the price of higher toxicity levels in situations of previous obstructive syndrome and urethral stenosis. A better integration of the therapeutic modalities available, brachytherapy included, should increase our curative possibilities in the radiation treatment of prostatic cancer.

[Mandibular osteoradionecrosis: sword of Damocles of radiotherapy for head and neck cancers?]. / L'ostéoradionécrose mandibulaire: épée de damoclès de la radiothérapie cervico-faciale?

Radiotherapy of head and neck cancer is efficient but may have severe late effects. Although unfrequent, mandibular radionecrosis is the most dreadful. A cascade of events leads from hyposialia to bone destruction through extensive caries and trauma linked to tooth removal. Prevention is based on oral hygiene and use of daily topical fluorides. Antibiotics and hyperbaric oxygen can be effective as a conservative management. Progressive osteonecrosis is best treated by mandible resection and reconstruction with microvascular free bone flaps. Patient compliance to prophylaxis is of major importance. The need for periodic follow-up under the supervision of the radiation oncologist is stressed and illustrated by a clinical case having experienced disastrous consequences.

Increased TGFbeta1 plasma level in patients with lung cancer: potential mechanisms.

BACKGROUND: Plasma transforming growth factor beta1 (TGFbeta1) levels are elevated in patients with lung cancer. As TGFbeta1 is mainly found in platelets and as nonmalignant pulmonary diseases (NMPD) are frequently associated with lung cancer, we investigated the potential contribution of platelet degranulation and/or of a concomitant NMPD to the increased plasma levels of TGFbeta1 reported in patients with lung cancer. MATERIALS AND METHODS: Blood samples were collected in duplicate from 30 healthy subjects, 14 patients suffering from NMPD and 37 patients with lung cancer. The platelet count was determined and the samples were processed to obtain plasma. One sample was collected in EDTA (EDTA plasma) and the other in a mixture inhibiting platelet degranulation (PIM plasma). TGFbeta1 concentrations and beta-thromboglobulin (betaTG) levels, an index of platelet degranulation, were measured in both plasma samples. RESULTS: TGFbeta1 and betaTG plasma levels measured in PIM plasma were lower than those obtained in EDTA plasma. With respect to PIM plasma, both TGFbeta1 and betaTG levels were higher in patients with lung cancer than those with NMPD and in healthy individuals. In patients with NMPD, only TGFbeta1 levels were increased as compared to healthy controls, betaTG levels being similar. CONCLUSION: Methods for collecting and processing blood samples are critical in determining reliable circulating TGFbeta1 levels. Increased TGFbeta1 plasma levels observed in patients with lung cancer are related, at least partly, to concomitant NMPD and also to platelet degranulation as proved by increased betaTG levels.

PSA kinetics after external beam radiotherapy alone or combined with an iridium brachytherapy boost to deliver 85 grays to prostatic adenocarcinoma.

PURPOSE: Increasing the dose to prostatic adenocarcinoma in conformal external beam therapy (EBT) has resulted in increased levels of PSA normalization and increased percentage of biochemical disease-free survival rates. However technical problems due to prostate motion inside the pelvis or patients' set-up make difficult the realization of the EBT boost fields above 72 Gy. Brachytherapy which overcomes these problems was investigated to deliver the boost dose to achieve 85 Gy. PSA nadir which has been identified as the strongest independent predictor of any failure in many studies has been used as the end point for early evaluation of this work. PATIENTS AND METHODS: In a retrospective way we report on 163 patients' PSA kinetics after EBT alone to 68 Gy or EBT first and a brachytherapy boost up to 75 or 85 Gy. RESULTS: At 12 months follow-up, PSA nadirs percentage < or = 0.5 or < or = 1 ng/ml increased from 7.5 and 20.7% after 68 Gy EBT to 49.8 and 71.2% after a brachytherapy boost to deliver 85 Gy (p < 0.0001). In the Cox PH model analysis, the total dose remained the most important factor for predicting PSA normalization. CONCLUSIONS: These results are in accordance with the most recent results published after conformal EBT at the same 80 Gy level of dose. If confirmed on a higher number of patients they could place brachytherapy among the most accurate methods of boosting in the radiation treatment of prostatic carcinoma.

[Benign diseases in radiotherapy: a practice survey in Belgium. Peer review of radiotherapy in Belgium]. / Affections bénignes et radiothérapie: une enquête de la pratique en Belgique. Peer review de radiothérapie de Belgique.

In 1996 and 2000, a survey of radiation practice in Belgium was performed by sending a questionnaire to the different centers asking their opinion and number of patients treated. There was a great similarity between the two surveys both for indications and total number of patients irradiated. For the most common indications (prevention of cheloids, heterotopic bone formation, hyperthyroidy ophthalmopathy), there was a trend to use similar radiation technique following recent publications. In contrast, if the number of cases of macular degeneration is declining, the prevention of vessels restenosis is becoming more and more an indication.

Minimally invasive endoscopic management of malignant sinonasal tumours.

A large retrospective study from two belgian institutions of 78 patients who underwent minimally invasive endoscopic management for malignant sinonasal tumors from, 1992-1999 is presented. We attempt to assess the results of this less invasive approach. The spectrum of disease included adenocarcinoma, squamous cell carcinoma, olfactory neuroblastoma and other malignant tumors. All patients were treated primarily for cure. 66 patients were operated on by a purely endoscopic technique, while 9 patients had a simultaneous neurosurgical and endoscopic approach, and 3 a limited orbital approach. 16 patients (20.5%) presented with local recurrence, 6 patients (7.7%) sustained distant metastases and 7 patients (9%) presented simultaneous local recurrence and distant metastases. The 2-years and 5-years survival rates of the whole group were respectively 73.1% and 52.3%, while the adenocarcinoma group exhibits a significantly better prognosis than other histological types with 2-years and 5-years survival rates of 89.8% and 63.8%. Patients who could be treated purely endoscopically had a significantly better survival in comparison to patients treated by an external and endoscopic approach. Morbidity was minimal and the local control rate as well as survival rates were comparable to literature data. Endoscopic resection was adequate, providing clear margins and en bloc removal in most cases. Our results encourage us to use this minimally invasive approach in selected cases as a reliable alternative to the systematic use of an exclusively external approach.

Radiotherapy in pediatric head and neck tumours.

According to international protocols, radiotherapy remains a part of the treatment of several pediatric ear, nose and throat tumours. The role of radiation therapy in the treatment of rhabdomyosarcomas, non-Hodgkin's lymphomas, nasopharyngeal carcinomas, osteosarcomas and juvenile nasopharyngeal angiofibromas is reviewed. The main complications of this type of treatment in children, as well as their management, are described. Finally, we discuss how several technical advances (increased fractionation of the dose, various types of stereotactic radiotherapy, use of tridimensional treatment planning systems) help the radiation oncologist to minimize the toxicity of the treatment for healthy tissues.

Evaluation of frequency and type of errors detected by a computerized record and verify system during radiation treatment.

BACKGROUND: Computerized record and verify systems (RVS) have been introduced to improve the precision of radiation treatment delivery. These systems prevent the delivery of ionizing radiations when the settings of the treatment machine do not match the intended parameters within some maximal authorized deviation. PURPOSE: To assess the potential alteration of the frequency of errors associated with the use of RVS during radiation treatment delivery. MATERIALS AND METHODS: The software of the RVS was altered in order to record the settings actually used for radiation treatment delivery whereas the verification function was suppressed. At the end of the study period, the settings used during daily administration of radiation treatment were compared to the parameters recorded in the RVS using the computer. They were also compared with the planned ones written in the patient treatment chart. RESULTS: Out of the 147,476 parameters examined during the study period, 678 (0.46%) were set erroneously. At least one error occurred in 628 (3.22%) of the 19,512 treated fields. An erroneous parameter was introduced in the RVS memory in 22 (1.17%) of the 1885 fields. CONCLUSIONS: RVS has the potential to improve precision of radiation treatment delivery by detecting a significant number of setting errors. However, excessive confidence in RVS could lead to repeated errors as there is a potential for the entry of erroneous parameters into the RVS memory.

18FDG-PET for the assessment of primary head and neck tumors: clinical, computed tomography, and histopathological correlation in 38 patients.

OBJECTIVES: To evaluate the clinical usefulness of FDG-PET (fluoro-2-deoxy-glucose-positron emission tomography) in the detection of lymph node involvement and recurrences in patients with head and neck cancer. STUDY DESIGN: Retrospective review of 38 patients with biopsy-proven head and neck cancers who underwent clinical, computed tomography (CT), and FDG-PET examinations. Twenty-five patients were studied prior to therapy and 13 patients were evaluated for disease recurrence. METHODS: All patients were operated and clinical data, CT, and FDG-PET results were correlated with histopathological findings. RESULTS: All primary tumors in 25 patients were detected, with the exception of one small superficial localization of the epiglottis. Histopathological examination showed lymph node involvement in 10 patients; PET detected lymph node involvement in five. FDG-PET found one case of nodal disease not identified by clinical and CT examination. With so few cases, this could be anecdotal. Five false-negative results (microscopic lymph node involvement) and two false positives were noted. Twelve of 13 patients with recurrent disease were correctly identified with FDG-PET. FDG-PET was the only imaging technique to identify local recurrence in two patients and lymph node involvement in two others. One false-positive result occurred in a patient with a foreign body granuloma. CONCLUSIONS: FDG-PET is a useful diagnostic modality for the detection of recurrent tumors and, in selected cases, precise lymph node involvement. The best way to further investigate the utility of clinical FDG-PET is in the follow-up of treated patients.

Detection of Epstein-Barr virus in a case of undifferentiated nasopharyngeal carcinoma by in situ hybridization with digoxigenin-labelled PCR-generated probes.

A case of nasopharyngeal carcinoma is presented. Epstein-Barr viral genome was identified in the neoplastic cells by in situ hybridization with digoxigenin-labelled polymerase chain reaction-generated probes. We report the development of this technique in paraffin-embedded sections and propose that such identification may prove valuable for the diagnosis of this tumour in routine material.

Enhancement of concomitant immunity after radiation therapy and immunotherapy in a syngeneic murine tumour system.

Concomitant immunity was evaluated in vivo towards a chemically induced epidermoid carcinoma transplanted in a syngeneic situation. Radiation therapy reversed the declining phase of concomitant immunity associated with tumour progression. The rejection rate of a challenge graft amounted to 82 and 95 per cent, respectively, 2 and 8 days after 25 Gy as compared with 55 and 43 per cent in unirradiated controls. Radiation induced immune recovery was dose related and proved to be different from restoration of immunity following surgical removal of the tumour. Immunotherapy with intraperitoneal injection of Corynebacterium parvum significantly improved concomitant immunity. Immunostimulation and irradiation at low dosage act synergistically on host anti-tumour resistance.