A 3D Convolutional Neural Network Based on Non-enhanced Brain CT to Identify Patients with Brain Metastases.

Dedicated brain imaging for cancer patients is seldom recommended in the absence of symptoms. There is increasing availability of non-enhanced CT (NE-CT) of the brain, mainly owing to a wider utilization of Positron Emission Tomography-CT (PET-CT) in cancer staging. Brain metastases (BM) are often hard to diagnose on NE-CT. This work aims to develop a 3D Convolutional Neural Network (3D-CNN) based on brain NE-CT to distinguish patients with and without BM. We retrospectively included NE-CT scans for 100 patients with single or multiple BM and 100 patients without brain imaging abnormalities. Patients whose largest lesion was < 5 mm were excluded. The largest tumor was manually segmented on a matched contrast-enhanced T1 weighted Magnetic Resonance Imaging (MRI), and shape radiomics were extracted to determine the size and volume of the lesion. The brain was automatically segmented, and masked images were normalized and resampled. The dataset was split into training (70%) and validation (30%) sets. Multiple versions of a 3D-CNN were developed, and the best model was selected based on accuracy (ACC) on the validation set. The median largest tumor Maximum-3D-Diameter was 2.29 cm, and its median volume was 2.81 cc. Solitary BM were found in 27% of the patients, while 49% had > 5 BMs. The best model consisted of 4 convolutional layers with 3D average pooling layers, dropout layers of 50%, and a sigmoid activation function. Mean validation ACC was 0.983 (SD: 0.020) and mean area under receiver-operating characteristic curve was 0.983 (SD: 0.023). Sensitivity was 0.983 (SD: 0.020). We developed an accurate 3D-CNN based on brain NE-CT to differentiate between patients with and without BM. The model merits further external validation.

Theragnostic Gadolinium-Based Nanoparticles Safely Augment X-ray Radiation Effects in Patients with Cervical Cancer.

Activated guided irradiation by X-ray (AGuIX) nanoparticles are gadolinium-based agents that have the dual benefit of mimicking the effects of a magnetic resonance imaging (MRI) contrast agent used in a clinical routine and enhancing the radiotherapeutic activity of conventional X-rays (for cancer treatment). This "theragnostic" action is explained on the one hand by the paramagnetic properties of gadolinium and on the other hand by the generation of high densities of secondary radiation following the interaction of ionizing radiation and high-Z atoms, which leads to enhanced radiation dose deposits within the tumors where the nanoparticles accumulate. Here, we report the results of a phase I trial that aimed to assess the safety and determine the optimal dose of AGuIX nanoparticles in combination with chemoradiation and brachytherapy in patients with locally advanced cervical cancer. AGuIX nanoparticles were administered intravenously and appropriately accumulated within tumors on a dose-dependent manner, as assessed by T1-weighted MRI, with a rapid urinary clearance of uncaught nanoparticles. We show that the observed tumor accumulation of the compounds can support precise delineation of functional target volumes at the time of brachytherapy based on gadolinium enhancement. AGuIX nanoparticles combined with chemoradiation appeared well tolerated among the 12 patients treated, with no dose-limiting toxicity observed. Treatment yielded excellent local control, with all patients achieving complete remission of the primary tumor. One patient had a distant tumor recurrence. These results demonstrate the clinical feasibility of using theranostic nanoparticles to augment the accuracy of MRI-based treatments while focally enhancing the radiation activity in tumors.

Automatic gross tumor volume segmentation with failure detection for safe implementation in locally advanced cervical cancer.

Background and Purpose: Automatic segmentation methods have greatly changed the RadioTherapy (RT) workflow, but still need to be extended to target volumes. In this paper, Deep Learning (DL) models were compared for Gross Tumor Volume (GTV) segmentation in locally advanced cervical cancer, and a novel investigation into failure detection was introduced by utilizing radiomic features. Methods and materials: We trained eight DL models (UNet, VNet, SegResNet, SegResNetVAE) for 2D and 3D segmentation. Ensembling individually trained models during cross-validation generated the final segmentation. To detect failures, binary classifiers were trained using radiomic features extracted from segmented GTVs as inputs, aiming to classify contours based on whether their Dice Similarity Coefficient ( DSC ) < T and DSC ⩾ T . Two distinct cohorts of T2-Weighted (T2W) pre-RT MR images captured in 2D sequences were used: one retrospective cohort consisting of 115 LACC patients from 30 scanners, and the other prospective cohort, comprising 51 patients from 7 scanners, used for testing. Results: Segmentation by 2D-SegResNet achieved the best DSC, Surface DSC ( SDSC 3 mm ), and 95th Hausdorff Distance (95HD): DSC = 0.72 ± 0.16, SDSC 3 mm =0.66 ± 0.17, and 95HD = 14.6 ± 9.0 mm without missing segmentation ( M =0) on the test cohort. Failure detection could generate precision ( P = 0.88 ), recall ( R = 0.75 ), F1-score ( F = 0.81 ), and accuracy ( A = 0.86 ) using Logistic Regression (LR) classifier on the test cohort with a threshold T = 0.67 on DSC values. Conclusions: Our study revealed that segmentation accuracy varies slightly among different DL methods, with 2D networks outperforming 3D networks in 2D MRI sequences. Doctors found the time-saving aspect advantageous. The proposed failure detection could guide doctors in sensitive cases.

An Explainable MRI-Radiomic Quantum Neural Network to Differentiate Between Large Brain Metastases and High-Grade Glioma Using Quantum Annealing for Feature Selection.

Solitary large brain metastases (LBM) and high-grade gliomas (HGG) are sometimes hard to differentiate on MRI. The management differs significantly between these two entities, and non-invasive methods that help differentiate between them are eagerly needed to avoid potentially morbid biopsies and surgical procedures. We explore herein the performance and interpretability of an MRI-radiomics variational quantum neural network (QNN) using a quantum-annealing mutual-information (MI) feature selection approach. We retrospectively included 423 patients with HGG and LBM (> 2 cm) who had a contrast-enhanced T1-weighted (CE-T1) MRI between 2012 and 2019. After exclusion, 72 HGG and 129 LBM were kept. Tumors were manually segmented, and a 5-mm peri-tumoral ring was created. MRI images were pre-processed, and 1813 radiomic features were extracted. A set of best features based on MI was selected. MI and conditional-MI were embedded into a quadratic unconstrained binary optimization (QUBO) formulation that was mapped to an Ising-model and submitted to D'Wave's quantum annealer to solve for the best combination of 10 features. The 10 selected features were embedded into a 2-qubits QNN using PennyLane library. The model was evaluated for balanced-accuracy (bACC) and area under the receiver operating characteristic curve (ROC-AUC) on the test set. The model performance was benchmarked against two classical models: dense neural networks (DNN) and extreme gradient boosting (XGB). Shapley values were calculated to interpret sample-wise predictions on the test set. The best 10-feature combination included 6 tumor and 4 ring features. For QNN, DNN, and XGB, respectively, training ROC-AUC was 0.86, 0.95, and 0.94; test ROC-AUC was 0.76, 0.75, and 0.79; and test bACC was 0.74, 0.73, and 0.72. The two most influential features were tumor Laplacian-of-Gaussian-GLRLM-Entropy and sphericity. We developed an accurate interpretable QNN model with quantum-informed feature selection to differentiate between LBM and HGG on CE-T1 brain MRI. The model performance is comparable to state-of-the-art classical models.

Analytical models for external photon beam radiotherapy out-of-field dose calculation: a scoping review.

A growing body of scientific evidence indicates that exposure to low dose ionizing radiation (< 2 Gy) is associated with a higher risk of developing radio-induced cancer. Additionally, it has been shown to have significant impacts on both innate and adaptive immune responses. As a result, the evaluation of the low doses inevitably delivered outside the treatment fields (out-of-field dose) in photon radiotherapy is a topic that is regaining interest at a pivotal moment in radiotherapy. In this work, we proposed a scoping review in order to identify evidence of strengths and limitations of available analytical models for out-of-field dose calculation in external photon beam radiotherapy for the purpose of implementation in clinical routine. Papers published between 1988 and 2022 proposing a novel analytical model that estimated at least one component of the out-of-field dose for photon external radiotherapy were included. Models focusing on electrons, protons and Monte-Carlo methods were excluded. The methodological quality and potential limitations of each model were analyzed to assess their generalizability. Twenty-one published papers were selected for analysis, of which 14 proposed multi-compartment models, demonstrating that research efforts are directed towards an increasingly detailed description of the underlying physical phenomena. Our synthesis revealed great inhomogeneities in practices, in particular in the acquisition of experimental data and the standardization of measurements, in the choice of metrics used for the evaluation of model performance and even in the definition of regions considered out-of-the-field, which makes quantitative comparisons impossible. We therefore propose to clarify some key concepts. The analytical methods do not seem to be easily suitable for massive use in clinical routine, due to the inevitable cumbersome nature of their implementation. Currently, there is no consensus on a mathematical formalism that comprehensively describes the out-of-field dose in external photon radiotherapy, partly due to the complex interactions between a large number of influencing factors. Out-of-field dose calculation models based on neural networks could be promising tools to overcome these limitations and thus favor a transfer to the clinic, but the lack of sufficiently large and heterogeneous data sets is the main obstacle.

Impact of radiation therapy on healthy tissues.

Radiation therapy has a fundamental role in the management of cancers. However, despite a constant improvement in radiotherapy techniques, the issue of radiation-induced side effects remains clinically relevant. Mechanisms of acute toxicity and late fibrosis are therefore important topics for translational research to improve the quality of life of patients treated with ionizing radiations. Tissue changes observed after radiotherapy are consequences of complex pathophysiology, involving macrophage activation, cytokine cascade, fibrotic changes, vascularization disorders, hypoxia, tissue destruction and subsequent chronic wound healing. Moreover, numerous data show the impact of these changes in the irradiated stroma on the oncogenic process, with interplays between tumor radiation response and pathways involved in the fibrotic process. The mechanisms of radiation-induced normal tissue inflammation are reviewed, with a focus on the impact of the inflammatory process on the onset of treatment-related toxicities and the oncogenic process. Possible targets for pharmacomodulation are also discussed.

Image-guided adaptive brachytherapy for advanced cervical cancer spreading to the bladder and/or rectum: Clinical outcome and prognostic factors.

INTRODUCTION: Refinements of brachytherapy techniques have led to better local control of locally advanced cervical cancer (LACC), especially with the development of image-guided adaptive brachytherapy (IGABT). Data on the efficacy of brachytherapy in cervical cancer spreading to adjacent organs are scarce. We report the experience of our institution in the treatment of these advanced tumors with IGABT. MATERIALS AND METHODS: Medical records of patients treated for a LACC spreading to the bladder and/or rectum between 2006 and 2020 at Gustave Roussy Institute were analyzed. Dosimetric parameters were collected and converted into 2 Gy per fraction equivalent doses, including the minimal dose received by 90% of the high-risk target volume (D90 CTVHR) and intermediate-risk target volume (D90 CTVIR), as well as the dose received by the most exposed 2 cm3 of the organs at risk. A Cox regression model was used to study the potential associations between clinical and dosimetric factors with survival endpoints and fistula formation. RESULTS AND STATISTICAL ANALYSIS: A total of 81 patients were identified. All patients received pelvic+/- para-aortic radiotherapy, 45 Gy in 25 fractions +/- boost to gross lymph nodes. Concomitant platinum-based chemotherapy was administered in 93.8% of cases. The median D90 CTVHR dose was 75.5 GyEQD2 (SD: 10.39 GyEQD2) and median CTVHR volume was 47.6 cm3 (SD: 27.9 cm3). Median bladder and rectal D2cm3 dose were 75.04 GyEQD2 (SD: 8.72 GyEQD2) and 64.07 GyEQD2 (SD: 6.68 GyEQD2). After a median follow-up of 27.62 ± 25.10 months, recurrence was found in 34/81 patients (42%). Metastatic failure was the most common pattern of relapse (n = 25). Use of a combined interstitial/intracavitary technique and D90 CTVHR ≥ 75.1 GyEQD2 were prognostic factors for OS in univariate analysis (HR = 0.24, 95%IC: 0.057-1, p = 0.023; HR = 0.2, 95%IC: 0.059-0.68, p = 0.0025, respectively). In multivariate analysis, a D90 CTVHR ≥ 75.1 GyEQD2 was significant for OS (HR = 0.23; 95%IC: 0.07, 0.78, p = 0.018). The occurrence of vesicovaginal fistula (VVF) was the most frequent pattern of local recurrence (HR = 4.6, 95%CI: 1.5-14, p = 0.01). CONCLUSION: Advances in brachytherapy modalities improved local control and survival while reducing toxicities. Enhancing local control through dose escalation and combined intracavitary/interstitial brachytherapy techniques is a major factor in patients cure probability, together with systemic intensification to better control distant events.

Providing Patients with Locally Advanced Cervical Cancer Access to Brachytherapy: Experience from a Referral Network for Women Treated in Overseas France.

Image-guided adaptive brachytherapy (IGABT) is part of the standard of care for locally advanced cervical cancer (LACC). Access to IGABT is limited in many regions, thus leading to treatment care disparities. We report the experience of a referral network for women with LACC between radiotherapy facilities in Overseas France and Gustave Roussy. This is a retrospective review of patients with LACC referred to Gustave Roussy, for pulsed-dose-rate (PDR) image-guided adaptive BT after initial radiation therapy in the French overseas between 2014 and 2021. Sixty-four patients were eligible to receive IGABT. Overall treatment time (OTT) was 60.5 days (IQR: 51−68.5). The median follow-up time was 17 months. At two years, estimated probabilities of LC, progression-free survival, and overall survival (OS) were 94.6% (95% CI: 88.9−100.0%), 72.7% (95% CI: 61.1−86.5%), and 82.5% (95% CI: 72.0−94.5%). In multivariable analysis, a D90CTVHR < 85GyEQD2 and a CTVHR volume > 40 cm3 were significant for poorer PFS (p = 0.001 and p = 0.009, respectively) and poorer OS (p = 0.004 and p = 0.004). The centralization of this advanced technique to expert centers requires a well-defined workflow and appropriate dimensioning of resources to minimize OTT.

Current Standards in the Management of Early and Locally Advanced Cervical Cancer: Update on the Benefit of Neoadjuvant/Adjuvant Strategies.

Globally, cervical cancers continue to be one of the leading causes of cancer-related deaths. The primary treatment of patients with early-stage disease includes surgery or radiation therapy with or without chemotherapy. The main challenge in treating these patients is to maintain a curative approach and limit treatment-related morbidity. Traditionally, inoperable patients are treated with radiation therapy solely and operable patients undergo upfront surgery followed by adjuvant (chemo) radiotherapy in cases with poor histopathological prognostic features. Patients with locally advanced cervical cancers are treated with concurrent chemoradiotherapy followed by an image-guided brachytherapy boost. In these patients, the main pattern of failure is distant relapse, encouraging intensification of systemic treatments to improve disease control. Ongoing trials are evaluating immunotherapy in locally advanced tumours following its encouraging efficacy reported in the recurrent and metastatic settings. In this article, clinical evidence of neoadjuvant and adjuvant treatments in cervical cancer patients is reviewed, with a focus on potential strategies to improve patients' outcome and minimize treatment-related morbidity.

Combined modality including novel sensitizers in gynecological cancers.

Standard treatment of locally advanced gynecological cancers relies mainly on platinum-based concurrent chemoradiotherapy followed by brachytherapy. Current chemotherapeutic drugs are only transiently effective and patients with advanced disease often develop resistance and subsequently, distant metastases despite significant initial responses of the primary tumor. In addition, some patients still develop local failure or progression, suggesting that there is still a place for increasing the anti-tumor radiation effect. Several strategies are being developed to increase the probability of curing patients. Vaginal cancer and vulva cancer are rare diseases, which resemble cervical cancer in their histology and pathogenesis. These gynecological cancers are predominantly associated with human papilloma virus infection. Treatment strategies in other unresectable gynecologic cancers are usually derived from evidence in locally advanced cervical cancers. In this review, we discuss mechanisms by which novel therapies could work synergistically with conventional chemoradiotherapy, from pre-clinical and ongoing clinical data. Trimodal, even quadrimodal treatment are currently being tested in clinical trials. Novel combinations derived from a metastatic setting, and being tested in locally advanced tumors, include anti-angiogenic agents, immunotherapy, tumor-infiltrating lymphocytes therapy, adoptive T-cell therapy and apoptosis inducers to enhance chemoradiotherapy efficacy through complementary molecular pathways. In parallel, radiosensitizers, such as nanoparticles and radiosensitizers of hypoxia aim to maximize the effect of radiotherapy locally.

Brachytherapy for the Conservative Treatment of Female Peri-Urethral Carcinoma.

Introduction: Peri-urethral cancers (PUC) are rare tumors. Brachytherapy (BT), either monotherapy or combined with radiation therapy, is a preferred treatment option to spare the morbidity of surgery and achieve organ preservation. We report, to the best of our knowledge, the largest experience of brachytherapy among women with PUC. Patients and Methods: This is a retrospective review of the medical records of female patients with PUC who underwent low- or pulse-dose-rate BT with or without external beam radiotherapy at Gustave Roussy between 1990 and 2018. Patients were categorized according to the treatment intention into a primary and recurrent group. The Kaplan-Meier method was used for survival analysis, and the Cox proportional-hazard model was used for univariate analysis. Brachythewharapy-related adverse events were reported according to Common Terminology Criteria for Adverse Events version 4. Results: We identified 44 patients with PUC who underwent BT. Of the 44 patients, 22 had primary tumors and 22 had recurrent tumors. Histologies were mainly adenocarcinoma (n = 20) and squamous cell carcinoma (n = 14). The median prescribed dose was 60 Gy for the 24 patients treated with BT alone and 20 Gy (IQ range: 15-56.25 Gy) for the 20 patients treated with BT in combination with EBRT. With a median follow-up of 21.5 months (range 7.5-60.8), a total of six patients experienced local relapse (17.5%). The 2-year overall survival probability was 63% (95%CI: 49.2-81.4%). The most common toxicities were acute genito-urinary grade 1-2 toxicities. At the last follow-up, four patients experienced focal necrosis. Conclusions: In this cohort of women with PUC undergoing BT, we observed an 80% probability of local control with acceptable morbidity. Though survival was poor, with high metastatic relapse probability, BT was useful to focally escalate the dose and optimize local control in the context of an organ sparing strategy.

Pulse-dose-rate interstitial brachytherapy in anal squamous cell carcinoma: clinical outcomes and patients' health quality perception.

PURPOSE: To examine clinical outcomes and quality of life of patients with anal squamous cell carcinoma treated with interstitial pulsed-dose-rate brachytherapy (PDR-BT) with a boost to residual tumor after external radiotherapy. MATERIAL AND METHODS: Medical records of patients receiving a brachytherapy boost after radiotherapy for anal squamous cell carcinoma in our Institute between 2008 and 2019 were retrospectively reviewed. After receiving pelvic irradiation ± concurrent chemotherapy, patients received PDR-BT boost to residual tumor, in order to deliver a minimal total dose of 60 Gy. Patients' outcomes were analyzed, with primary focus on local control, sphincter preservation, morbidity, and quality of life. RESULTS: A total of 42 patients were identified, included 24, 13, and 5 patients with I, II, and III tumor stages, respectively. Median brachytherapy (BT) dose was 20 Gy (range, 10-30 Gy). Median dose per pulse was 42 cGy (range, 37.5-50 cGy). With median follow-up of 60.4 months (range, 5.4-127.4 months), estimated local control and colostomy-free survival rates at 5 years were both 88.7% (95% CI: 67.4-96.4%). The largest axis of residual lesion after external beam radiation therapy (EBRT) and poor tumor shrinkage were associated with more frequent relapses (p = 0.02 and p = 0.007, respectively). Out of 40 patients with more than 6 months follow-up, only one experienced severe delayed toxicity (fecal incontinence). Health quality perception was very good or good in 20 of 22 (91%) patients, according to their replies of quality-of-life surveys. A total dose ≥ 63 Gy was associated with higher number of anorectal grade 1+ toxicities (n = 1.5 vs. n = 0.61, p = 0.02). CONCLUSIONS: In this cohort of 42 patients with mainly I and II tumor stages, PDR-BT boost allowed for local control in 88.7% of patients, with only one grade 3 anorectal toxicity.

Prospective evaluation of intensity-modulated radiotherapy toxicity in extremity soft tissue sarcomas patients: A role for irradiated healthy soft tissue volume?

AIM: To prospectively assess toxicities of curative-intent intensity-modulated conformal radiotherapy (IMRT) in patients with extremity soft tissue sarcomas (ESTS). METHODS: Data from 59 consecutive patients with ESTS between 2014 and 2019 were both retrospectively and prospectively analysed. Toxicity data were collected both by confidential mailed survey (39% completed) and medical charts, and graded according to CTCAE v5.0. Normal tissues dosimetric data (healthy soft tissue segment, joint and bone) were included. The healthy soft tissue segment was created by adding 5 cm on either side of the PTV on CT axial slices, the PTV and bone (and articulation if present) were then removed from the generated volume. RESULTS: IMRT was delivered post-operatively for nearly half of patients (n = 24, 41%), preoperatively for 18 (31%) and exclusively for 17 (28%; salvage: 13% or immediately inoperable: 15%). The median total dose delivered to the planned target volume (PTV) was 50.4 Gy (36-68 Gy) and 13 patients (22%) received a boost. With a median follow-up of 27 months (6-94 months), a total of 87 late effects were identified in 44/59 (75%) patients: 89% G1-2, and 11% G3-4. The main G1-2 toxicities were: functional limitation (36%), oedema (29%), gait disorders (20%), neurological disorders (20%) and chronic pain (32%). G3-4 toxicities were pain (n = 2), arterial stricture (n = 1) and a chronic wound requiring skin graft (n = 2). No bone fracture was observed. Quality of life was rated as good or very good in 70% patients who completed the survey. Larger (>3500 cm3) healthy soft tissue segment volume was associated with decreased late toxicities (p = 0.02). No other predictive factor of toxicity was identified. The 2-year rates of local control, overall survival and recurrence-free survival were 90%, 90% and 64%, respectively. CONCLUSION: Healthy soft tissue segment volume influenced toxicity. Long-term prospective monitoring in a homogeneous population remains critical to assess the impact of IMRT induced chronic toxicity in ESTS patients. This should ideally lead to a validated normal tissue dose constraint (e.g.: healthy soft tissue segment volume > 3500 cm3) to recommend for practitioners to help reduce the late toxicity risk.

Systematic Screening of COVID-19 Disease Based on Chest CT and RT-PCR for Cancer Patients Undergoing Radiation Therapy in a Coronavirus French Hotspot.

PURPOSE: Patients with cancer are presumed to be more vulnerable to COVID-19. We evaluated a screening strategy combining chest computed tomography (CT) and reverse-transcription polymerase chain reaction (RT-PCR) for patients treated with radiation therapy at our cancer center located in a COVID-19 French hotspot during the first wave of the pandemic. METHODS AND MATERIALS: Chest CT images were proposed during radiation therapy CT simulation. Images were reviewed by an expert radiologist according to the COVID-19 Reporting and Data System classification. Nasal swabs with RT-PCR assay were initially proposed in cases of suspicious imaging or clinical context and were eventually integrated into the systematic screening. A dedicated radiation therapy workflow was proposed for COVID-19 patients to limit the risk of contamination. RESULTS: From March 18, 2020 to May 1, 2020, 480 patients were screened by chest CT, and 313 patients had both chest CT and RT-PCR (65%). The cumulative incidence of COVID-19 was 5.4% (95% confidence interval [CI], 3.6-7.8; 26 of 480 patients). Diagnosis of COVID-19 was made before radiation therapy for 22 patients (84.6%) and during RT for 4 patients (15.3%). Chest CT directly aided the diagnosis of 7 cases in which the initial RT-PCR was negative or not feasible, out of a total of 480 patients (1.5%) and 517 chest CT acquisitions. Four patients with COVID-19 at the time of the chest CT screening had a false negative CT. Sensitivity and specificity of chest CT screening in patients with both RT-PCR and chest CT testing were estimated at 0.82 (95% CI, 0.60-0.95) and 0.98 (95% CI, 0.96-0.99), respectively. Adaptation of the radiation therapy treatment was made for all patients, with 7 postponed treatments (median: 5 days; interquartile range, 1.5-14.8). CONCLUSIONS: The benefit of systematic use of chest CT screening during CT simulation for patients undergoing radiation therapy during the COVID-19 pandemic seemed limited.

Incorporating Magnetic Resonance Imaging (MRI) Based Radiation Therapy Response Prediction into Clinical Practice for Locally Advanced Cervical Cancer Patients.

In recent years, magnetic resonance imaging (MRI) has become one of the standard imaging tools to define the macroscopic gross tumor volume in locally advanced cervical cancer patients based on T2-weighted sequence. Recent data suggest that functional MRI could be used to potentially improve the delineation of target volumes based on physiologic features, defining radioresistant subvolumes that may require higher doses to achieve local cure. Functional imaging can be used to predict tumor biology and outcome, as well as for assessment of tumor response during radiotherapy. The concept of adaptive radiotherapy relies on the possibility of monitoring variations in target volumes structures to guide treatment-plan modification during radiotherapy, taking into account not only internal movements but also tumor response. With integrated MRI in radiotherapy linear accelerators, motion monitoring during treatment delivery has become available. MRI can be also used to accurately evaluate cervical tumor residual volume after chemoradiotherapy, and therefore allowing a personalized treatment planning for brachytherapy boost, based on tumor radiosensitivity. In this review, we discuss how MRI tumor response assessment could be included into clinical practice during radiation therapy in locally advanced cervical cancer patients.

Hypnosedation for endocavitary uterovaginal applications: A pilot study.

PURPOSE: Implantations for uterovaginal brachytherapy are usually performed under general or spinal anesthesia, which are not without risk. As it is a rather short procedure and since postoperative pain is minimal, hypnosedation was proposed to selected patients requiring endocavitary applications as part of their routine treatment. METHODS AND MATERIALS: Consecutive patients requiring intracavitary uterovaginal brachytherapy from January to October 2019 were included if they accepted the procedure. A premedication was systematically administered. Hypnosedation was based on an Ericksonian technique. The procedure was immediately interrupted if the patient requested it, in cases of extreme anxiety or pain. Procedure was in that case rescheduled with a "classical" anesthesia technique. RESULTS: A total of 20 patients were included. Four patients had to be converted toward a general anesthesia: one because of a fibroma on the probe's way and three young patients with a very anteverted/retroverted uterus that was painful at every mobilization. Mean and maximum pain scores during implant were 2.9/10 and 5.1/10, respectively. The most painful maneuver was cervical dilation for 45% of the patients, followed by mold insertion in 40% of cases. About 85% of the patients declared that hypnosis helped them relax; 90% of the patients would recommend the technique. No procedure-related complication occurred. CONCLUSION: With a 70% success rate (correct implant with mean pain and anxiety scores < 5), one can conclude that uterovaginal brachytherapy implantation under hypnosedation is feasible and received a high satisfaction rate from the patients. This technique may reduce overall treatment time in a context of difficult access to the OR and to anesthesiologists, while reducing anesthetic drugs resort and postoperative nausea.